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What is Lifestyle Medicine
About
Services
Chip Program
CPR, AED and First Aid
Genetic Testing - Nutrigenomics & Pharmacogenomics
The Lift Project
1-on-1 Program
Diabetes Prevention Program
Programs + Products
Network
Providers
Employers
Partners
Resources
Helpful Links
FAQ
Patient Forms
Health History Questionnaire
Agreement to Receive Electronic Communication
Payment Policies
General Patient Information Form
New Patient Assessment Form
24 Hour Food Options Form
Request to Participate (CHIP)
Request to Participate (LIFT)
Blog
Lifestyle Medicine Options
Contact
New Patient Assessment Form
Name
*
First Name
Last Name
Gender
*
Age
*
Email
*
Nutrition
*
ON AN AVERAGE DAY, how many servings of whole fruits and vegetables do you eat? (1 serving is about a handful and does not include fruit juice)
Less than 2 servings
2 to 3 servings
4 to 5 servings
More than 5 servings
How often have you eaten unhealthy foods? (e.g., fast food, chips, cookies, candy, sugar- sweeten beverages, fried food, package or processed foods, red meat, egg yolks, high fat dairy products (milk and/or cheese), sugar, and salt)
*
Not at all
Occasionally (2 or 3 times/week)
Moderately (one time day)
Nearly with every meal
Salty food - How often do you eat salty foods (such as soy sauce, pickles, canned meats, salted nuts or potato or corn chips)?
*
Not at all
Occasionally (2 or 3 times/week)
Moderately (one time day)
Nearly with every meal
Fiber preferences - How often do you choose to eat high-fiber foods such as whole wheat bread or pasta, high-fiber breakfast cereal and brown rice?
*
Not at all
Occasionally (2 or 3 times/week)
Moderately (one time day)
Nearly with every meal
Practice good eating habits? (e.g., sitting down to meals, incorporating mindful eating or not working through lunch)
*
Not at all;
Several days
More than half of the days
Nearly every day
How many glasses of water do you drink in a day?
*
One or less;
2 to 4
4 to 6
8 or more
How many sugar-sweetened beverages or sodas do you have in a day?
*
None
One
Two
3 or more
How many caffeinated beverages do you drink each day? Please include regular tea, coffee, espressos, lattes, or caffeinated soft drinks?
*
None
One
Two
3 or more
On a scale from 1 to 10, how important is it for you to improve your nutrition? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, how confident are you that you can make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
Exercise
*
EXERCISE Over the last four weeks On average, how many days per week do you engage in moderate to strenuous exercise? (like a brisk walk)
None
1-2x Week
3-4x Week
5 or more x Week
On average, how many minutes do you engage in exercise at this level?
*
None; At least 10 minutes
At least 30 minutes
At least 60 minutes
On average, how many days a week do you engage in strength training or resistance exercises?(e.g., lifting weights, using body weight, bands, heavy gardening or work)
*
None
1x week
2x week
3 x or more per week
Rate your balance(e.g. steady on your feet walking and stairs, able to balance on 1 leg for at least 10 seconds, no falls in 6 months)
*
Very Poor
Poor
Faire
Good
Very Good
Rate your flexibility (e.g. able to touch your toes, reach behind your back and touch your shoulder blade)
*
Very Poor
Poor
Faire
Good
Very Good
On a scale from 1 to 10, how important is it for you to improve your physical activity? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, how confident are you that you can make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
Substance Abuse
*
In the last 4 weeks How many times did you use tobacco (including cigarettes, cigars, chew and e-cigarettes)
None
1-2x Day
3-4x Day
5 or more x Day
Are you a current user? Past user? Never used? Please check one:
*
Yes
No
Never used
In case you answer YES to the above question, you are using tobacco for how many years?
*
1 year
2 years
years
4 years
5 or more years
How often do you have a drink containing alcohol?
*
None
1/day
/day
3/day
4/day
5/day
6 or more/day
How many drinks containing alcohol do you have on a typical day when you are drinking?
*
None
1/day
/day
3/day
4/day
5/day
6 or more/day
How often do you have six or more drinks on one occasion?
*
1/month
2/month
3/month
4/month
5/month or more
On a scale from 1 to 10, how important is it for you to make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, how confident are you that you can make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
Stress Management
*
Over the last 4 weeks On a rate 1 (never) to 5 (very often) please rate yourself Upset because of something that happened unexpectedly?
1
2
3
4
5
Unable to control the important things in your life?
*
1
2
3
4
5
Felt nervous and stressed?
*
1
2
3
4
5
Felt confident about your ability to handle your personal problems?
*
1
2
3
4
5
Felt that things were going your way?
*
1
2
3
4
5
Could not cope with all the things that you had to do?
*
1
2
3
4
5
Able to control irritations in your life?
*
1
2
3
4
5
Felt that you were on top of things?
*
1
2
3
4
5
Angered because of things that happened that were outside of your control?
*
1
2
3
4
5
Felt difficulties were piling up so high that you could not overcome them?
*
1
2
3
4
5
On a scale from 1 to 10, how important is it for you to improve your stress coping mechanism? 1 not all important- 10 extremely important
*
1
2
3
4
5
On a scale from 1 to 10, how confident are you that you can make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
Sleep
*
Over the last 4 weeks How many hours of sleep did you average in a 24-hour period?
Less than 4 hours
4 to 5 hours
6 hours
to 9 hours
more than 10 hours
How many hours do you sleep during the week days?
*
Less than 4 hours
4 to 5 hours
6 hours
7 to 9 hours
more than 10 hours
How many hours do you sleep during the week-end?
*
Less than 4 hours
4 to 5 hours
6 hours
7 to 9 hours
more than 10 hours
How do you perceive your sleep qualify?
*
Very Poor
Poor
Faire
Good
Very Good
Easily fall and stay asleep? (including not getting up to use the bathroom)
*
Not at all
Several Nights
More than half of the nights
Nearly every night
Do you wake up feeling refreshed and energized?
*
Not at all
Several Days
More than half of the days
Nearly every day
On a scale from 1 to 10, how important is it for you to improve your sleep?1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, how confident are you that you can make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
EMOTIONAL AND MENTAL WELL-BEING
*
In most ways, is my life is close to my ideal?
1
2
3
4
5
I am satisfied with my life?
*
1
2
3
4
5
On a scale 0 to 3 (0 not at all; 1 several days; 2 more than half of the days; 3 nearly every day)
*
Over the past two weeks, have you felt down, depressed or hopeless?
0
1
2
3
4
Over the past two weeks, have you felt little interest or pleasure in doing things?
*
0
1
2
3
4
On a scale 0 to 3 (0 not at all; 1 several days; 2 more than half of the days; 3 nearly every day)
*
In the last two week, how often have you felt nervous, anxious or on the edge?
0
1
2
3
In the last two weeks, how often have you not been able to stop or control worrying?
*
0
1
2
3
On a scale from 1 to 10, how important is it for you to improve your emotional and well-being? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, how confident are you that you can make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
Relationship
*
Over the last four weeks How many times did you use social support from family, friends or community?
Never
Rarely
Sometimes
Often
Always
Do you have a comfortable, healthy space where you work and live?
*
Never
Rarely
Sometimes
Often
Always
On a scale from 1 to 10, how important is it for you to improve how you live? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, how confident are you that you can make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, how important is it for you to improve your relations? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, how confident are you that you can make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
Your Self
*
Date Of Birth
MM
DD
YYYY
How many years of education have you completed?
*
What is your current or previous occupation?
*
In the Last 5 Years what was your highest weight?
In the last 5 years what was your lowest weight?
What is your desired weight?
*
What is your current weight?
*
What is your height without shoes?
*
Over the last four weeks Did you take care of yourself? (e.g., being compliant and staying up to date on preventative care, health screening, medications and treatment plan as appropriate)
*
Never
Rarely
Sometimes
Often
Always
Other:
Do you practice daily mind-body medicine techniques to manage stress?(e.g., deep breathing, meditation, relaxation exercises, Yoga, tai chi, listening or playing music, spiritual/religious activities)
*
Never
Rarely
Sometimes
Often
Always
On a scale from 1 to 10, how important is it for you to improve your self-care? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, how confident are you that you can make some healthy changes? 1 not all important- 10 extremely important
*
1
2
3
4
5
6
7
8
9
10
Please rank 1-5 the areas you are most motivated to change in order to improve your current overall health 1 being the most important to you
*
Exercise
1
2
3
4
5
Nutrition
*
1
2
3
4
5
Sleep
*
1
2
3
4
5
Stress management
*
1
2
3
4
5
Substance Abuse
*
1
2
3
4
5
Stress Management
*
1
2
3
4
5
Substance Abuse
*
1
2
3
4
5
Relationship
*
1
2
3
4
5
Emotional Well Being
*
1
2
3
4
5
Thank you!