Events

Lifestyle Medicine Assessment

Lifestyle Assessment Form

Alabama Lifestyle Medicine

Step 1 of 8

12%

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

What is your current overall LEVEL OF HEALTH

Please 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 Health

What 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

Other

Sleep

Please answer based on your sleeping patterns OVER the LAST TWO WEEKS

How often have you had difficulty staying awake during routine tasks?

Never

Seldom

Sometimes

Often

Always

How often have you had difficulty staying awake while driving?

Never

Seldom

Sometimes

Often

Always

How often have you felt fatigued or needed to nap during the day?

Never

Seldom

Sometimes

Often

Always

How often has it taken you more than 30 minutes to fall asleep at night?

Never

Seldom

Sometimes

Often

Always

How often have you woken up at night?

Never

Seldom

Sometimes

Often

Always

How often have you unintentionally woken up early in the morning?

Never

Seldom

Sometimes

Often

Always

How often do you look at a screen within 2 hours of sleeping (i.e. TV, computer, iPad, or Phone)?

Never

Seldom

Sometimes

Often

Always

How often have your legs or arms jerked during sleep?

Never

Seldom

Sometimes

Often

Always

How often have you experienced “creeping” or “crawling” feelings in your legs?

Never

Seldom

Sometimes

Often

Always

How often have you snored loudly, gasped, choked, or stopped breathing during sleep?

Never

Seldom

Sometimes

Often

Always

How 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

Always

Do you have a job that requires night shifts?

Never

Seldom

Sometimes

Often

Always

Do you have a medical condition or chronic pain that interferes with your sleep?

Never

Seldom

Sometimes

Often

Always

On an average weekday do you get at least 7-8 hours of sleep in a 24-hour period?

Never

Seldom

Sometimes

Often

Always

On an average weekend do you get at least 7-8 hours of sleep in a 24-hour period? 1 2

Never

Seldom

Sometimes

Often

Always

Nutrition

Please answer based on your typical eating habits

On average, how many cups (8 oz.) of caffeinated beverages do you drink per day (tea, soda, coffee, or energy drinks)?

On average, how many servings of alcohol do you drink per day?

On average, how many cups (8 oz.) of sugary drinks (soda, sports drinks, juice) do you drink per day?

On average, how often do you snack on convenience or “junk” food per day? (i.e. chips, candy, granola bars, crackers, cookies, etc.)

On average, how many meals do you buy from a restaurant or fast food per week?

On average, do you drink at least 8 glasses of water per day?

Yes

Do you use natural or artificial sweeteners? (i.e. Equal, Stevia, Splenda, Sweet & Low, honey, agave, etc.)

Yes

On average, do you eat at least 5 handfuls of nuts per week?

Yes

Do you add salt to most of your meals?

Yes

Do you eat processed meats (i.e. sausage, hot dogs, salami, bacon)?

Yes

Do 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

Other

Do 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

Other

Food Recall

Please record below what AND how much you ate and drank yesterday (or the last typical day)

Breakfast

Time

Hours

Minutes

AM/PM

Lunch

Time

Hours

Minutes

AM/PM

Dinner

Time

Hours

Minutes

AM/PM

Snacks

Time

Hours

Minutes

AM/PM

Drinks/Beverages

Time

Hours

Minutes

AM/PM

Weight Management

Please answer based on your typical eating habits

How often do you skip meals?

Never

Seldom

Sometimes

Often

Always

How often do you snack in between meals?

Never

Seldom

Sometimes

Often

Always

How often do you eat while watching TV?

Never

Seldom

Sometimes

Often

Always

How often do you eat while in bed?

Never

Seldom

Sometimes

Often

Always

How often do you have difficulty sleeping?

Never

Seldom

Sometimes

Often

Always

How often do you lack physical activity or exercise?

Never

Seldom

Sometimes

Often

Always

How often do you feel a lack of purpose or meaning in your life?

Never

Seldom

Sometimes

Often

Always

Do 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 often

Which 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 Situations

Weight History

Have you ever been overweight or obese?

Yes

Were you overweight as a child?

Yes

Were you overweight as a teenager?

Yes

Were you overweight between the ages of 20-29?

Yes

Were you overweight between the ages of 30-39?

Yes

Were you overweight above the age of 40?

Yes

Are you currently trying to lose or gain weight?

Yes

Have you ever intentionally lost or reduced your weight by more than 5 lbs.?

Yes

If yes, did you regain weight within 1 year?

Yes

Have you had weight loss surgery?

Yes

Are you currently trying to lose or gain weight?

Lose Weight

Gain Weight

Have 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

Other

Have 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

Other

Which 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

Other

Exercise

During 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

Other

Are 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

Other

Do 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

Other

Mental Health

Percieved Stress

How often have you felt that you were unable to control the important things in your life?

Never

Seldom

Sometimes

Often

Always

How often have you felt that things were not going your way?

Never

Seldom

Sometimes

Often

Always

Have often have you found it hard to let go of things that upset you?

Never

Seldom

Sometimes

Often

Always

How 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

Other

Resilience

I find a way to learn from my experience.

Never

Seldom

Sometimes

Often

Always

I find a way to take action.

Never

Seldom

Sometimes

Often

Always

I find it easy to prioritize what is important in my life.

Never

Seldom

Sometimes

Often

Always

I look at a stressful situation as an opportunity to grow.

Never

Seldom

Sometimes

Often

Always

I meet the goals I set for myself

Never

Seldom

Sometimes

Often

Always

I believe that there are a lot of ways around a problem.

Never

Seldom

Sometimes

Often

Always

I feel motivated to pursue my goals.

Never

Seldom

Sometimes

Often

Always

I know I can get through it.

Never

Seldom

Sometimes

Often

Always

MIND-BODY CONNECTION

I meet the goals I set for myself

Never

Seldom

Sometimes

Often

Always

Do thoughts or feelings affect your physical health?

Never

Seldom

Sometimes

Often

Always

Could you be experiencing some emotion and not be aware of it?

Never

Seldom

Sometimes

Often

Always

Are you aware of tension in your body?

Never

Seldom

Sometimes

Often

Always

Do you notice how your body changes when angry?

Never

Seldom

Sometimes

Often

Always

Do you notice stress in your body?

Never

Seldom

Sometimes

Often

Always

Do you notice how your body reacts to emotions?

Never

Seldom

Sometimes

Often

Always

Depression

Over 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

Daily

Feeling down, depressed or hopeless.

Not at all

Several Days

Most Days

Daily

Trouble falling asleep, staying asleep, or sleeping too much.

Not at all

Several Days

Most Days

Daily

Feeling tired or having little energy

Not at all

Several Days

Most Days

Daily

Poor appetite or overeating.

Not at all

Several Days

Most Days

Daily

Feeling bad about yourself or that you’re a failure or have let yourself or your family down.

Not at all

Several Days

Most Days

Daily

Trouble concentrating on things, such as reading the newspaper or watching television.

Not at all

Several Days

Most Days

Daily

Moving 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

Daily

Thoughts that you would be better off dead or of hurting yourself in some way.

Not at all

Several Days

Most Days

Daily

Anxiety

Over 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

Always

Feeling nervous, anxious, or on edge

Not at all

Several Days

Most Days

Daily

Not being able to stop or control worrying.

Not at all

Several Days

Most Days

Daily

Worrying too much about different things.

Not at all

Several Days

Most Days

Daily

Trouble relaxing.

Not at all

Several Days

Most Days

Daily

Being so restless that it’s hard to sit still.

Not at all

Several Days

Most Days

Daily

Becoming easily annoyed or irritable.

Not at all

Several Days

Most Days

Daily

Trouble concentrating on things, such as reading the newspaper or watching television.

Not at all

Several Days

Most Days

Daily

Moving 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

Daily

Thoughts that you would be better off dead or of hurting yourself in some way.

Not at all

Several Days

Most Days

Daily

PURPOSE AND CONNECTION

How often do you agree with the following:

I live a purposeful and meaningful life

Never

Seldom

Sometimes

Often

Always

I have a spiritual community that I can turn to in times of need

Never

Seldom

Sometimes

Often

Always

I am satisfied with my current belief system

Never

Seldom

Sometimes

Often

Always

I am satisfied with my current belief system

Never

Seldom

Sometimes

Often

Always

I have people who care about what happens to me

Never

Seldom

Sometimes

Often

Always

I have people who accept me at my worst and best.

Never

Seldom

Sometimes

Often

Always

I have people I trust at home or work who I can talk to about my problems

Never

Seldom

Sometimes

Often

Always

I get help when I’m sick

Never

Seldom

Sometimes

Often

Always

SMOKING AND SUBSTANCE HISTORY

Do you use nicotine products?

Yes

If yes, do you want to quit using the nicotine/tobacco products?

Yes

How soon after you wake up do you use nicotine/tobacco?

Within 5 minutes

6-30 minutes

31-60 minutes

After 60 minutes

How 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

other

At 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

Are 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

other

Have you used any methods in the past other than medications to try to quit?

Yes

If yes, check which of the following methods you have used:

Self-help

Gradual reduction

Cold turkey

Acupuncture

Special filters

Vaping/e-cigarettes

other

Alcohol

What 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

Have people Annoyed you by criticizing your drinking?

Yes

Have you ever felt Guilty about your drinking?

Yes

Have you ever had a drink in the morning to steady your nerves or to get rid of a hangover (eye opener)?

Yes

Do you binge drink (more than 5 drinks for men or 4 drinks for women within 2 hours)?

Yes

Have you used Recreational drugs (cocaine, heroin, meth, etc.) in the past year?

Yes

Have you used Marijuana in the past year?

Yes

If yes, what level of concern do you have regarding use of the substances

1 (worst)

5 (best)

Have you ever received treatment for a mental health problem?

Yes

Have you ever received treatment for drug or alcohol use?

Yes

MEDICAL 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.

Digestive

Diarrhea

Constipation

Bloated feeling

Belching, passing gas

Heartburn

Intestinal/stomach pain

Nausea or vomiting

Emotions

Mood swings

Anxiety, fear, nervousness

Anger, irritability, aggressiveness

Depression

Ears

Itchy ears

Earaches, ear infections

Drainage from ear

Ringing in ears, hearing loss

Head

Headaches

Faintness or lightheadedness

Dizziness

Insomnia

Heart

Chest pain

Irregular or skipped heartbeat

Rapid or pounding heartbeat

JOINTS/MUSCLES

Pains or aches in joints

Arthritis

Stiffness or limitations of movement

Pain or aches in muscles

Feeling of weakness or tiredness

LUNGS

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficulty breathing

Mind

Poor memory

Poor Confusion, poor comprehension

Poor concentration

Poor physical coordination

Difficulty making decisions

Learning disabilities

Stuttering or stammering

Slurred speech

ENERGY/ACTIVITY

Fatigue, sluggishness

Hyperactivity

Apathy, lethargy

Restlessness

Eyes

Watery or itchy eyes

Bags or dark circles under eyes

Swollen, reddened or sticky eyelids

Blurred or tunnel vision (does not include near or far sightedness)

Nose

Stuffy Nose

Sinus problems

Excessive mucous formation

Hay fever

Nose

Acne

Hives, rashes, dry skin

Hair loss

Flushing or hot flushes

Excessive sweating

Weight

Binge eating/drinking

Craving certain foods

Excessive weight

Underweight

Compulsive eating

Water retention

Other

Frequent illness

Frequent or urgent urination

Genital itch or discharge

Key

Add individual scores and total each group. Add each group score to give a grand total.