ABOUT SSL CERTIFICATES Health and Lifestyle Questionnaire Download a printable version of the form here Name: Date of Birth: Visit Date: Please tell us the reason for your visit: Weight History: How tall are you> Desired or goal weight: Lowest adult weight: When: Highest adult weight (non-pregnant): When: If you are overweight, when did you begin gaining excess weight? Starting a new job After High School After College After getting married After having children After surgery/injury Other Please list weight loss programs, diets, or medications you have tried, with approximate dates: DIET START DATE END DATE Atkin's LA Weight Loss Cambridge Jenny Craig Medifast Nutrasystems Optifast TOPS South Beach Weight Watchers Maximum weight lost on any program: Eating pattern Where are most meals eaten? At home alone At home with family At home with a friend At restaurants alone At restaurants with family At restaurants with a friend Where do you purchase or obtain food? Do you receive SNAP Benefits? yes no Do you have food allergies or intolerances? Any household special dietary restrictions? Who usually cooks? Who grocery shops? Favorite foods: Food dislikes: "Problem foods": What percent of the time do you spend thinking about food and your weight? Are you uncomfortable with how much you eat? yes no Do you eat differently when you are alone? Do you have difficulty chewing? yes no Do you have trouble swallowing? yes no Do you wear dentures? yes no Do you have difficulty swallowing pills? yes no If you are overweight, what are some reasons? Low level of physical activity Eating/snacking too many times daily Amounts of food eaten Kinds of foods eaten Eating out too often Lack of knowledge Eating too fast Social events Irregular meal and snack times Eating due to boredom or stress Lack of other satisfactions Overeating when alone Using food as reward or comfort Love the taste of food Any eating problems? Anorexia nervosa Binge eating Bulimia Induced vomiting Laxative abuse Waking at night to eat Other: None Emotions associated with eating: Anger Anxiety Boredom Control Depression Enjoyment Hunger Guilt Stress Other: Do you think you are currently undergoing a stressful situation? Yes No If 'yes' please explain: Activity and exercise Previous activity/exercise: Current activity/exercise: Do you have any of these physical limitations? Chest discomfort Dizziness Joint swelling Back pain Foot pain Joint pain Knee pain Leg pain Muscle pain Shortness of breath Torn ligaments Tobacco use Tobacco Use: Never Former Type: Amount: Current Type: Amount: Start Date: Stop Date: Are you exposed to second hand smoke? yes no Food pattern How often do you eat the following foods and beverages? Daily Weekly Seldom Never Milk, yogurt Vegetables Fruit Red meat Poultry, fish Sweets Regular soda Fast or fried food How would you describe the size of your servings? Small Average Large How much tea, coffee, or other caffeinated beverages do you consume? What other beverages do you drink? If you have not been keeping a food record, please jot down what you eat and drink on a typical day. If you never have a "typical" day, please write down what you ate yesterday: Breakfast: Morning snacks: Lunch: Afternoon snacks: Dinner: Evening snacks: The following three questions are for bariatric patients only - others please continue below. What kind of surgery are you interested in? What type of exercise do you plan to do when recovered from surgery? Please check how your partner, spouse, family, friends, or employer feel about your planned surgery: Very criticalNeutralVery supportive Not applicableDoes not know Partner/Spouse Family Friends Employer ALL—continue here. Please indicate whether your medical history includes any of these problems: YesNoProblem HistoryComments Anxiety Cancer Diabetes Depression Difficulty breathing High blood pressure High cholesterol Heart disease Mental illness Obesity Osteoarthritis Osteoporosis Rheumatoid arthritis Sleep apnea Stomach/digestive problems Stroke Thyroid disease Other Women Only: Do you have menstrual periods? yes no If yes: How frequent are your periods? How long do they last? How heavy are they? What do you use for contraception? If no, please check reason: Hysterectomy Menopause Other-please describe: Do you have any leakage of urine when you cough, sneeze or exercise? yes no ALL—continue here: Surgeries and medically related events (for example: appendectomy, heart attack): Surgery or Medical Event Date Additional Surgery or Medical Event Information: Family history Please indicate who in your family has had these problems (include parents, grandparents, siblings and children) Yes No Problem History Family Member(s) Cancer - type Diabetes High blood pressure High cholesterol Heart disease Mental illness Obesity Osteoarthritis Osteoporosis Rheumatoid arthritis Stroke Thyroid disease Other Medications and Supplements: Please list any prescription and non-prescription medications you are taking. If you have a current list, please bring it with you instead of filling this section out. Medication/Supplement Dose Medication/Supplement Dose Allergies: Please list any drug or food allergies or intolerances, and what symptoms you have Do you have latex allergies? Yes No Social History: What is your occupation? What is your current employment status? Who lives in your household? Relationship Status: How much do you sleep each day, on average? Usual bedtime: Usual wake-up time: Alcohol Intake:None Number of drinks on occassion Number of days per week you drink Recreational drugs: Yes No For all patients: Please let us know if you have any additional comments and questions. Thank you for taking the time to answer our questions. Your efforts allow us to be more prepared for your clinic visit. We ask you to please check the box below, indicating that this information is accurate to the best of your ability. We look forward to seeing you in clinic. Sincerely, The Cayuga Center for Healthy Living Team The above information provided is accurate to the best of my ability. 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Download a printable version of the form here
Internet privacy disclaimer: Although we have taken extensive security precautions, we cannot guarantee absolute privacy of the information submitted through this form. You must understand that there is a risk that in some circumstances, it may be possible for others to see the information submitted through this form while it's transmitted to our computer.
I have read and agreed to the privacy policy of this website.
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