Lifestyle Medicine AssessmentLifestyle Assessment FormAlabama Lifestyle MedicineStep 1 of 812%Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY What is your current overall LEVEL OF HEALTHPlease enter a number from 1 to 10.Select 3 areas you would like to improve with Sleep Exercise Substance Use Weight Management Purpose & Connection Nutrition Mental HealthWhat was your most Important improvement?What was your 2nd most Important improvement?What was your 3rd most Important improvement?How IMPORTANT is it for you to make the change you ranked as the #1 most motivated topic area to address?Please enter a number from 1 to 10.How CONFIDENT are you regarding your ability to make the change you ranked as the #1 most motivated topic area to address?Please enter a number from 1 to 10.How IMPORTANT is it for you to make the change you ranked as the #2 most motivated topic area to address?Please enter a number from 1 to 10.How CONFIDENT are you regarding your ability to make the change you ranked as the #2 most motivated topic area to address?Please enter a number from 1 to 10.How IMPORTANT is it for you to make the change you ranked as the #3 most motivated topic area to address?Please enter a number from 1 to 10.How CONFIDENT are you regarding your ability to make the change you ranked as the #3 most motivated topic area to address?Please enter a number from 1 to 10.What would you like to gain from this lifestyle visit? Check all that apply More medical/scientific knowledge Practical health tips Personalized plan Accountability OtherSleepPlease answer based on your sleeping patterns OVER the LAST TWO WEEKSHow often have you had difficulty staying awake during routine tasks? Never Seldom Sometimes Often AlwaysHow often have you had difficulty staying awake while driving? Never Seldom Sometimes Often AlwaysHow often have you felt fatigued or needed to nap during the day? Never Seldom Sometimes Often AlwaysHow often has it taken you more than 30 minutes to fall asleep at night? Never Seldom Sometimes Often AlwaysHow often have you woken up at night? Never Seldom Sometimes Often AlwaysHow often have you unintentionally woken up early in the morning? Never Seldom Sometimes Often AlwaysHow often do you look at a screen within 2 hours of sleeping (i.e. TV, computer, iPad, or Phone)? Never Seldom Sometimes Often AlwaysHow often have your legs or arms jerked during sleep? Never Seldom Sometimes Often AlwaysHow often have you experienced “creeping” or “crawling” feelings in your legs? Never Seldom Sometimes Often AlwaysHow often have you snored loudly, gasped, choked, or stopped breathing during sleep? Never Seldom Sometimes Often AlwaysHow often have you used sleeping aids (i.e. tobacco, alcohol, over-the-counter medications, or prescription medications) to help you fall asleep? Never Seldom Sometimes Often AlwaysDo you have a job that requires night shifts? Never Seldom Sometimes Often AlwaysDo you have a medical condition or chronic pain that interferes with your sleep? Never Seldom Sometimes Often AlwaysOn an average weekday do you get at least 7-8 hours of sleep in a 24-hour period? Never Seldom Sometimes Often AlwaysOn an average weekend do you get at least 7-8 hours of sleep in a 24-hour period? 1 2 Never Seldom Sometimes Often AlwaysNutritionPlease answer based on your typical eating habitsOn average, how many cups (8 oz.) of caffeinated beverages do you drink per day (tea, soda, coffee, or energy drinks)? 0 1 2 3 4+On average, how many servings of alcohol do you drink per day? 0 1 2 3 4+On average, how many cups (8 oz.) of sugary drinks (soda, sports drinks, juice) do you drink per day? 0 1 2 3 4+On average, how often do you snack on convenience or “junk” food per day? (i.e. chips, candy, granola bars, crackers, cookies, etc.) 0 1 2 3 4+On average, how many meals do you buy from a restaurant or fast food per week? 0 1 2 3 4+On average, do you drink at least 8 glasses of water per day? Yes NoDo you use natural or artificial sweeteners? (i.e. Equal, Stevia, Splenda, Sweet & Low, honey, agave, etc.) Yes NoOn average, do you eat at least 5 handfuls of nuts per week? Yes NoDo you add salt to most of your meals? Yes NoDo you eat processed meats (i.e. sausage, hot dogs, salami, bacon)? Yes NoDo you have any bad reactions (sensitivities or allergies) to food? If yes, please list here:Do you avoid any particular foods? If yes, please list here: Do you have foods that you crave? If yes, please list here: Are you currently following a particular diet or nutrition plan? If yes, please list here:During the last 3 months, did you have any episodes of excessive overeating? If yes please explain here:Are you concerned about making the wrong food choices? If yes, please explain here:Have you ever had an eating disorder? If yes, please list here:Do you use any of the following VITAMINS or SUPPLEMENTS? Check all that apply Vitamin D Calcium Vitamin B12 Probiotics Omega 3 Multivitamin OtherDo you use any of the following OILS with your meals or cooking? Check all that apply Olive Oil Canola Oil Vegetable Oil Coconut Oil Butter Lard OtherFood RecallPlease record below what AND how much you ate and drank yesterday (or the last typical day)BreakfastTime : AMPM AM/PMLunchTime : AMPM AM/PMDinnerTime : AMPM AM/PMSnacksTime : AMPM AM/PMDrinks/BeveragesTime : AMPM AM/PMWeight ManagementPlease answer based on your typical eating habitsHow often do you skip meals? Never Seldom Sometimes Often AlwaysHow often do you snack in between meals? Never Seldom Sometimes Often AlwaysHow often do you eat while watching TV? Never Seldom Sometimes Often AlwaysHow often do you eat while in bed? Never Seldom Sometimes Often AlwaysHow often do you have difficulty sleeping? Never Seldom Sometimes Often AlwaysHow often do you lack physical activity or exercise? Never Seldom Sometimes Often AlwaysHow often do you feel a lack of purpose or meaning in your life? Never Seldom Sometimes Often AlwaysDo any of the following situations or emotions cause you to eat? Check all that apply Like Healthy Eating Fast eater Rely on packaged or fast foods Do not plan meals Late night eater No time to prepare healthy foodchoices Don’t like healthy food Eat slowly Dislike cooking Eat a variety of foods Negative relationship to food Don’t know how to cook Know how to cook healthy foods Read nutrition labels Prepare meals at home Always hungry Erratic eater Live alone or eat alone oftenWhich of the following factors apply to your eating habits and current lifestyle? Check all that apply Sadness Pain Insomnia Anxiety Fatigue Boredom Stress Social or Family SituationsWeight HistoryHave you ever been overweight or obese? Yes NoWere you overweight as a child? Yes NoWere you overweight as a teenager? Yes NoWere you overweight between the ages of 20-29? Yes NoWere you overweight between the ages of 30-39? Yes NoWere you overweight above the age of 40? Yes NoAre you currently trying to lose or gain weight? Yes NoHave you ever intentionally lost or reduced your weight by more than 5 lbs.? Yes NoIf yes, did you regain weight within 1 year? Yes NoHave you had weight loss surgery? Yes NoAre you currently trying to lose or gain weight? Lose Weight Gain WeightHave you ever used weight loss medications? Check all that apply. If other, please list. Acutin Alli Amphetamines Anorex Belviq Byetta Contrave Dexatrim Didrex Fastin Fenfluramine Mazanor Maridia Obalan Phendiet Fen-Phen Phentermine Plegine Prozac Pondimin Qsymia Redux Sanorex tenuate Tepanol Vyvanse Wechless welbutrin Xenical I don't remember the name of the medication OtherHave you tried any of the following alternative therapies or programs? Check all that apply. If other, please list. Acupuncture Acupressure Nutritionist/Registered Dietitian Residential Programs Hypnosis Physical Activity/Exercises OtherWhich commercial or fad diets have you tried in the past? Check all that apply. If other, please list. Atkins Diet Low Fat Calorie Counting Paleo CHIP South Beach DASH Vegan Vegetarian Jenny Craig Weight Watchers Low Carb Slim Fast/MealReplacement OtherExerciseDuring the average week, how many days do you do strength/resistance training? Please enter a number from 1 to 7.During an average session, how many minutes do you exercise at a moderate to strenuous intensity (i.e. brisk walking or enough movement to break a light sweat)?List types of aerobic activities you do (i.e. walking, jogging, swimming, bicycling, dancing, etc.): During the average week, how many days do you exercise at a moderate to strenuous intensity (i.e. brisk walking or enough to break a light sweat)? Please enter a number from 1 to 7.How many minutes do you exercise per week with strength/resistance training?List types of activities you do (i.e. weightlifting, Pilates, kettle ball, resistance machines, exercise bands, etc.): What MOTIVATES you or would motivate you to exercise? Check top three Nothing would motivate me Control Blood glucose Decrease stress Increase self-esteem Family or partner Improve mood Weight reduction Body Image Increase Energy Reduce blood pressure Prevent heart disease Prevent Bone loss Improve sleep OtherAre there any BARRIERS or PROBLEMS that limit exercise? Check all that apply No barriers Life Transition Period Family Responsibility Depression Time Apparel Work Responsibility Fear Energy Cost OtherDo you have any injuries that would make it difficult to exercise? If yes, please explain: Do you have any joint, muscle, or bone problems that might get worse with exercise? If yes, please explain: Do you have any breathing problems while exercising? If yes, please explain: Do you have any balance problems or have had a fall in the last 6 months? If yes, please explain:Do you have any difficulty completing your activities of daily living (i.e. showering, dressing, toileting)? If yes, please explain:Do you have any of the following health problems? Check all that apply Arrhythmia or irregular heartbeat Uncontrolled diabetes Recent heart attack Arthritis or significant joint pain Severe or uncontrolled heartfailure Chronic or unusual fatigue/tiredness Chest pain/angina Uncontrolled asthma Difficulty breathing with activity OtherMental HealthPercieved StressHow often have you felt that you were unable to control the important things in your life? Never Seldom Sometimes Often AlwaysHow often have you felt that things were not going your way? Never Seldom Sometimes Often AlwaysHave often have you found it hard to let go of things that upset you? Never Seldom Sometimes Often AlwaysHow do you COPE with stress? Check all that apply Meditation Exercise/Physical Activity Counseling/Psychotherapy Socializing with friends or family Art Food (too much, too little) Sex Recreational drugs (i.e.marijuana, cocaine, etc.) Television and/or videogames Gambling Journaling Massage/Body work Prayer Substance (tobacco,alcohol) Distraction Hurting yourself (i.e.cutting, etc.) Pet therapy OtherResilienceI find a way to learn from my experience. Never Seldom Sometimes Often AlwaysI find a way to take action. Never Seldom Sometimes Often AlwaysI find it easy to prioritize what is important in my life. Never Seldom Sometimes Often AlwaysI look at a stressful situation as an opportunity to grow. Never Seldom Sometimes Often AlwaysI meet the goals I set for myself Never Seldom Sometimes Often AlwaysI believe that there are a lot of ways around a problem. Never Seldom Sometimes Often AlwaysI feel motivated to pursue my goals. Never Seldom Sometimes Often AlwaysI know I can get through it. Never Seldom Sometimes Often AlwaysMIND-BODY CONNECTIONI meet the goals I set for myself Never Seldom Sometimes Often AlwaysDo thoughts or feelings affect your physical health? Never Seldom Sometimes Often AlwaysCould you be experiencing some emotion and not be aware of it? Never Seldom Sometimes Often AlwaysAre you aware of tension in your body? Never Seldom Sometimes Often AlwaysDo you notice how your body changes when angry? Never Seldom Sometimes Often AlwaysDo you notice stress in your body? Never Seldom Sometimes Often AlwaysDo you notice how your body reacts to emotions? Never Seldom Sometimes Often AlwaysDepressionOver the last 2 weeks, how often have you been bothered by the following?Little interest or pleasure in doing things. Not at all Several Days Most Days DailyFeeling down, depressed or hopeless. Not at all Several Days Most Days DailyTrouble falling asleep, staying asleep, or sleeping too much. Not at all Several Days Most Days DailyFeeling tired or having little energy Not at all Several Days Most Days DailyPoor appetite or overeating. Not at all Several Days Most Days DailyFeeling bad about yourself or that you’re a failure or have let yourself or your family down. Not at all Several Days Most Days DailyTrouble concentrating on things, such as reading the newspaper or watching television. Not at all Several Days Most Days DailyMoving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. Not at all Several Days Most Days DailyThoughts that you would be better off dead or of hurting yourself in some way. Not at all Several Days Most Days DailyAnxietyOver the last 2 weeks, how often have you been bothered by the following?Do you notice how your body reacts to emotions? Never Seldom Sometimes Often AlwaysFeeling nervous, anxious, or on edge Not at all Several Days Most Days DailyNot being able to stop or control worrying. Not at all Several Days Most Days DailyWorrying too much about different things. Not at all Several Days Most Days DailyTrouble relaxing. Not at all Several Days Most Days DailyBeing so restless that it’s hard to sit still. Not at all Several Days Most Days DailyBecoming easily annoyed or irritable. Not at all Several Days Most Days DailyTrouble concentrating on things, such as reading the newspaper or watching television. Not at all Several Days Most Days DailyMoving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. Not at all Several Days Most Days DailyThoughts that you would be better off dead or of hurting yourself in some way. Not at all Several Days Most Days DailyPURPOSE AND CONNECTIONHow often do you agree with the following:I live a purposeful and meaningful life Never Seldom Sometimes Often AlwaysI have a spiritual community that I can turn to in times of need Never Seldom Sometimes Often AlwaysI am satisfied with my current belief system Never Seldom Sometimes Often AlwaysI am satisfied with my current belief system Never Seldom Sometimes Often AlwaysI have people who care about what happens to me Never Seldom Sometimes Often AlwaysI have people who accept me at my worst and best. Never Seldom Sometimes Often AlwaysI have people I trust at home or work who I can talk to about my problems Never Seldom Sometimes Often AlwaysI get help when I’m sick Never Seldom Sometimes Often AlwaysSMOKING AND SUBSTANCE HISTORYDo you use nicotine products? Yes NoIf yes, do you want to quit using the nicotine/tobacco products? Yes NoHow soon after you wake up do you use nicotine/tobacco? Within 5 minutes 6-30 minutes 31-60 minutes After 60 minutesHow many cigarettes do you smoke per day? 10 or less 11-20 21-30 31+Which of the following people smoke around you? Check all that apply Friends Family Partner Co-Workers otherAt what age did you start smoking? How many times have you seriously tried to quit? What is the longest time period you have stayed quit? For your most recent quit attempt, how long did it last? What made you start smoking again? Who is supporting you to quit smoking? What is your most important reason to quit smoking? Are you currently using or have used any medications to help you quit smoking? Yes NoAre you currently using or have used any medications to help you quit smoking? Nicotine Patch Nicotine Gum Wellbutrin/Bupropion Pill Chantix/ Varenicline Pill Nicotine Lozenge otherHave you used any methods in the past other than medications to try to quit? Yes NoIf yes, check which of the following methods you have used: Self-help Gradual reduction Cold turkey Acupuncture Special filters Vaping/e-cigarettes otherAlcoholWhat type of alcohol do you prefer? On average, how many servings do you drink per day/week/month/year on average? Have you ever felt you should “Cut down” on your drinking? Yes NoHave people Annoyed you by criticizing your drinking? Yes NoHave you ever felt Guilty about your drinking? Yes NoHave you ever had a drink in the morning to steady your nerves or to get rid of a hangover (eye opener)? Yes NoDo you binge drink (more than 5 drinks for men or 4 drinks for women within 2 hours)? Yes NoHave you used Recreational drugs (cocaine, heroin, meth, etc.) in the past year? Yes NoHave you used Marijuana in the past year? Yes NoIf yes, what level of concern do you have regarding use of the substances 1 (worst) 2 3 4 5 (best)Have you ever received treatment for a mental health problem? Yes NoHave you ever received treatment for drug or alcohol use? Yes NoMEDICAL SYMPTOM QUESTIONNAIRE (MSQ)Points Scale: 0 = Never or almost never have the symptom. 1 = Occasionally have it, effect is not severe. 2 = Occasionally have, effect is severe. 3 = Frequently have it, effect is not severe. 4 = Frequently have it, effect is severe.DigestiveDiarrhea 0 1 2 3 4Constipation 0 1 2 3 4Bloated feeling 0 1 2 3 4Belching, passing gas 0 1 2 3 4Heartburn 0 1 2 3 4Intestinal/stomach pain 0 1 2 3 4Nausea or vomiting 0 1 2 3 4EmotionsMood swings 0 1 2 3 4Anxiety, fear, nervousness 0 1 2 3 4Anger, irritability, aggressiveness 0 1 2 3 4Depression 0 1 2 3 4EarsItchy ears 0 1 2 3 4Earaches, ear infections 0 1 2 3 4Drainage from ear 0 1 2 3 4Ringing in ears, hearing loss 0 1 2 3 4HeadHeadaches 0 1 2 3 4Faintness or lightheadedness 0 1 2 3 4Dizziness 0 1 2 3 4Insomnia 0 1 2 3 4HeartChest pain 0 1 2 3 4Irregular or skipped heartbeat 0 1 2 3 4Rapid or pounding heartbeat 0 1 2 3 4JOINTS/MUSCLESPains or aches in joints 0 1 2 3 4Arthritis 0 1 2 3 4Stiffness or limitations of movement 0 1 2 3 4Pain or aches in muscles 0 1 2 3 4Feeling of weakness or tiredness 0 1 2 3 4LUNGSChest congestion 0 1 2 3 4Asthma, bronchitis 0 1 2 3 4Shortness of breath 0 1 2 3 4Difficulty breathing 0 1 2 3 4MindPoor memory 0 1 2 3 4Poor Confusion, poor comprehension 0 1 2 3 4Poor concentration 0 1 2 3 4Poor physical coordination 0 1 2 3 4Difficulty making decisions 0 1 2 3 4Learning disabilities 0 1 2 3 4Stuttering or stammering 0 1 2 3 4Slurred speech 0 1 2 3 4ENERGY/ACTIVITYFatigue, sluggishness 0 1 2 3 4Hyperactivity 0 1 2 3 4Apathy, lethargy 0 1 2 3 4Restlessness 0 1 2 3 4EyesWatery or itchy eyes 0 1 2 3 4Bags or dark circles under eyes 0 1 2 3 4Swollen, reddened or sticky eyelids 0 1 2 3 4Blurred or tunnel vision (does not include near or far sightedness) 0 1 2 3 4NoseStuffy Nose 0 1 2 3 4Sinus problems 0 1 2 3 4Excessive mucous formation 0 1 2 3 4Hay fever 0 1 2 3 4NoseAcne 0 1 2 3 4Hives, rashes, dry skin 0 1 2 3 4Hair loss 0 1 2 3 4Flushing or hot flushes 0 1 2 3 4Excessive sweating 0 1 2 3 4WeightBinge eating/drinking 0 1 2 3 4Craving certain foods 0 1 2 3 4Excessive weight 0 1 2 3 4Underweight 0 1 2 3 4Compulsive eating 0 1 2 3 4Water retention 0 1 2 3 4OtherFrequent illness 0 1 2 3 4Frequent or urgent urination 0 1 2 3 4Genital itch or discharge 0 1 2 3 4KeyAdd individual scores and total each group. Add each group score to give a grand total.PREVENTIVE SERVICESPlease Type "Yes", "No", or "I don't know"Have you had a physical exam and/or “Wellness” Visit in the past 12 months? If yes, list date and outcome:Have you had a dental exam and teeth cleaning in the past 12 months? If yes, list date and outcome:Have you been screened for diabetes with blood work? If yes, list date and outcome:Have you had your cholesterol, lipids or triglycerides measured? If yes, list date and outcome:Have you ever had a bone density test to check for osteoporosis? If yes, list date and outcome:Do you have any balance problems or have had a fall in the last 6 months? If yes, list date and outcome:Do you have any difficulty completing your activities of daily living (i.e. showering, dressing, toileting)? If yes, list date and outcome:Do you have any concerns about your ability to drive safely or have you had any car accidents in the past 12 months? If yes, list date and outcome:Do you have any concerns about your memory? If yes, list date and outcome:Do you have any trouble with your hearing? If yes, list date and outcome:Have you had your eyes checked for vision problems? If yes, list date and outcome:Have you ever had your metabolism or thyroid checked? If yes, list date and outcome:Have you ever been told that you have a sexually transmitted disease/infection? If yes, list date and outcome:If you smoke, have you ever had an abdominal ultrasound to check for possible aneurysms? If yes, list date and outcome:Which of the following screenings have you completed Weight managementor obesity Nutrition Smoking or use of othernicotine products Alcohol useHave you ever received counseling behavioral therapy for any of the following problems? Colon cancer screen (stool testor colonoscopy Breast cancer screen(mammogram) Cervical cancer screen (PAPsmear) HIV/AIDS blood work screen Hepatitis C blood work screen Depression or sadness screenHave you had the following vaccines? Flu Hepatitis B Pneumococcal or PneumoniaEmailThis field is for validation purposes and should be left unchanged.
