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Birmingham, AL 35233
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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)?
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
No
Do you use natural or artificial sweeteners? (i.e. Equal, Stevia, Splenda, Sweet & Low, honey, agave, etc.)
Yes
No
On average, do you eat at least 5 handfuls of nuts per week?
Yes
No
Do you add salt to most of your meals?
Yes
No
Do you eat processed meats (i.e. sausage, hot dogs, salami, bacon)?
Yes
No
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
AM/PM
Lunch
Time
Hours
:
Minutes
AM
PM
AM/PM
Dinner
Time
Hours
:
Minutes
AM
PM
AM/PM
Snacks
Time
Hours
:
Minutes
AM
PM
AM/PM
Drinks/Beverages
Time
Hours
:
Minutes
AM
PM
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
No
Were you overweight as a child?
Yes
No
Were you overweight as a teenager?
Yes
No
Were you overweight between the ages of 20-29?
Yes
No
Were you overweight between the ages of 30-39?
Yes
No
Were you overweight above the age of 40?
Yes
No
Are you currently trying to lose or gain weight?
Yes
No
Have you ever intentionally lost or reduced your weight by more than 5 lbs.?
Yes
No
If yes, did you regain weight within 1 year?
Yes
No
Have you had weight loss surgery?
Yes
No
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
No
If yes, do you want to quit using the nicotine/tobacco products?
Yes
No
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
No
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
No
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
No
Have people Annoyed you by criticizing your drinking?
Yes
No
Have you ever felt Guilty about your drinking?
Yes
No
Have you ever had a drink in the morning to steady your nerves or to get rid of a hangover (eye opener)?
Yes
No
Do you binge drink (more than 5 drinks for men or 4 drinks for women within 2 hours)?
Yes
No
Have you used Recreational drugs (cocaine, heroin, meth, etc.) in the past year?
Yes
No
Have you used Marijuana in the past year?
Yes
No
If 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
No
Have you ever received treatment for drug or alcohol use?
Yes
No
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
0
1
2
3
4
Constipation
0
1
2
3
4
Bloated feeling
0
1
2
3
4
Belching, passing gas
0
1
2
3
4
Heartburn
0
1
2
3
4
Intestinal/stomach pain
0
1
2
3
4
Nausea or vomiting
0
1
2
3
4
Emotions
Mood swings
0
1
2
3
4
Anxiety, fear, nervousness
0
1
2
3
4
Anger, irritability, aggressiveness
0
1
2
3
4
Depression
0
1
2
3
4
Ears
Itchy ears
0
1
2
3
4
Earaches, ear infections
0
1
2
3
4
Drainage from ear
0
1
2
3
4
Ringing in ears, hearing loss
0
1
2
3
4
Head
Headaches
0
1
2
3
4
Faintness or lightheadedness
0
1
2
3
4
Dizziness
0
1
2
3
4
Insomnia
0
1
2
3
4
Heart
Chest pain
0
1
2
3
4
Irregular or skipped heartbeat
0
1
2
3
4
Rapid or pounding heartbeat
0
1
2
3
4
JOINTS/MUSCLES
Pains or aches in joints
0
1
2
3
4
Arthritis
0
1
2
3
4
Stiffness or limitations of movement
0
1
2
3
4
Pain or aches in muscles
0
1
2
3
4
Feeling of weakness or tiredness
0
1
2
3
4
LUNGS
Chest congestion
0
1
2
3
4
Asthma, bronchitis
0
1
2
3
4
Shortness of breath
0
1
2
3
4
Difficulty breathing
0
1
2
3
4
Mind
Poor memory
0
1
2
3
4
Poor Confusion, poor comprehension
0
1
2
3
4
Poor concentration
0
1
2
3
4
Poor physical coordination
0
1
2
3
4
Difficulty making decisions
0
1
2
3
4
Learning disabilities
0
1
2
3
4
Stuttering or stammering
0
1
2
3
4
Slurred speech
0
1
2
3
4
ENERGY/ACTIVITY
Fatigue, sluggishness
0
1
2
3
4
Hyperactivity
0
1
2
3
4
Apathy, lethargy
0
1
2
3
4
Restlessness
0
1
2
3
4
Eyes
Watery or itchy eyes
0
1
2
3
4
Bags or dark circles under eyes
0
1
2
3
4
Swollen, reddened or sticky eyelids
0
1
2
3
4
Blurred or tunnel vision (does not include near or far sightedness)
0
1
2
3
4
Nose
Stuffy Nose
0
1
2
3
4
Sinus problems
0
1
2
3
4
Excessive mucous formation
0
1
2
3
4
Hay fever
0
1
2
3
4
Nose
Acne
0
1
2
3
4
Hives, rashes, dry skin
0
1
2
3
4
Hair loss
0
1
2
3
4
Flushing or hot flushes
0
1
2
3
4
Excessive sweating
0
1
2
3
4
Weight
Binge eating/drinking
0
1
2
3
4
Craving certain foods
0
1
2
3
4
Excessive weight
0
1
2
3
4
Underweight
0
1
2
3
4
Compulsive eating
0
1
2
3
4
Water retention
0
1
2
3
4
Other
Frequent illness
0
1
2
3
4
Frequent or urgent urination
0
1
2
3
4
Genital itch or discharge
0
1
2
3
4
Key
Add individual scores and total each group. Add each group score to give a grand total.
PREVENTIVE SERVICES
Please 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 use
Have 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 screen
Have you had the following vaccines?
Flu
Hepatitis B
Pneumococcal or Pneumonia
Name
This field is for validation purposes and should be left unchanged.
48084
32359