2208 University Blvd Suite 102
Birmingham, AL 35233

$0.00 0 Cart

Services
Patients
Events

Services
Patients
Events

Services
Patients
Events
About
Blog
Contact

Services
Patients
Events
About
Blog
Contact

About
Blog
Contact

About
Blog
Contact

Lifestyle Assessment Form

Step 1 of 12

Patient Name

First Last

Date Of Birth

MM slash DD slash YYYY

Current overall LEVEL OF HEALTH(Required)

Please rank the top 3 areas you would like to improve with.(Required)

Sleep

Weight Management

Nutrition

Exercise

Purpose & Connection

Mental Health

Substance Use

How IMPORTANT is it for you to make the change you ranked as the #1 most motivated topic area to address?(Required)

How CONFIDENT are you regarding your ability to make the change you ranked as the #1 most motivated topic area to address?(Required)

How IMPORTANT is it for you to make the change you ranked as the #2 most motivated topic area to address?(Required)

How CONFIDENT are you regarding your ability to make the change you ranked as the #2 most motivated topic area to address?(Required)

How IMPORTANT is it for you to make the change you ranked as the #3 most motivated topic area to address?(Required)

How CONFIDENT are you regarding your ability to make the change you ranked as the #3 most motivated topic area to address?(Required)

What would you like to gain from this lifestyle visit? Check all that apply.(Required)

More medical/scientific knowledge

Practical health tips

Other

Accountability

Personalized plan

Please specify

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

1=Never 2=Seldom 3=Sometimes 4=Often 5=Always

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

How often have you had difficulty staying awake while driving?(Required)

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

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

How often have you woken up at night?(Required)

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

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

How often have your legs or arms jerked during sleep?(Required)

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

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

How often have you used sleeping aids (i.e. tobacco, alcohol, over-the-counter medications, or prescription medications) to help you fall asleep?(Required)

Do you have a job that requires night shifts?(Required)

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

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

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

Eating Patterns

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)?(Required)

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

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

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

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

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

Yes

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

Yes

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

Yes

Do you add salt to most of your meals?(Required)

Yes

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

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

Please Specify

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

Please Specify

Food Recall

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

Breakfast

Time

Lunch

Time

Dinner

Time

Snacks

Time

Drinks/Beverages

Time

Behavior Patterns

1=Never 2=Seldom 3=Sometimes 4=Often 5=Always

How often do you skip meals?(Required)

How often do you snack in between meals?(Required)

How often do you eat while watching TV?(Required)

How often do you eat while in bed?(Required)

How often do you have difficulty sleeping?(Required)

How often do you lack physical activity or exercise?(Required)

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

Which of the following factors apply to your eating habits and current lifestyle? Check all that apply.

Like healthy food

Don’t like healthy food

Know how to cook healthy foods

Fast eater

Eat slowly

Read nutrition labels

Rely on packaged or fast foods

Dislike cooking

Prepare meals at home

Do not plan meals

Eat a variety of foods

Always hungry

Late night eater

Negative relationship to food

Erratic eater

No time to prepare healthy food choices

Don’t know how to cook

Live alone or eat alone often

Do any of the following situations or emotions cause you to eat? Check all that apply.

Sadness

Pain

Insomnia

Anxiety

Fatigue

Social or Family Situations

Boredom

Stress

Weight History

Have you ever been overweight or obese?(Required)

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?(Required)

Yes

What is your goal?

Lose weight

Gain weight

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

Yes

Did you regain weight within 1 year?

Yes

Have you had weight loss surgery?(Required)

Yes

Please list the type of surgery you had

Have you ever used weight loss medications?(Required)

Yes

Which ones you have used?

Acutrim

Alli

Amphetamines

Anorex

Belviq

Byetta

Contrave

Dexatrim

Didrex

Fastin

Fenfluramine

Mazanor

Meridia

Obalan

Phendiet

Fen-Phen

Phentermine

Plegine

Prozac

Pondimin

Qsymia

Redux

Sanorex

Tenuate

Tepanol

Vyvanse

Wechless

Wellbutrin

Xenical

I don't remember the name of the medication

Other

Please Specify

Weight Loss Strategies

Have you tried any of the following alternative therapies or programs? Check all that apply.

Acupuncture

Acupressure

Nutritionist/Registered Dietitian

Residential Programs

Hypnosis

Physical Activity/Exercises

Other

Please Specify

Which commercial or fad diets have you tried in the past? Check all that apply.

Atkins Diet

Low Fat

Calorie Counting

Paleo

CHIP

South Beach

DASH

Vegan

Mediterranean Diet

Elimination Diet (Allergy)

Gluten Free

Vegetarian

Jenny Craig

Weight Watchers

Low Carb

Slim Fast/Meal Replacement

Other

Please Specify

Exercise Habits: Aerobic/Cardio Training

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)?(Required)

Numerical values only

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)?(Required)

Numerical values only

This field is hidden when viewing the form

Total min/week (days x min)

List types of aerobic activities you do (i.e. walking, jogging, swimming, bicycling, dancing, etc.)(Required)

During the average week, how many days do you do strength/resistance training?(Required)

Numerical values only

How many minutes do you exercise with strength/resistance training?(Required)

Numerical values only

This field is hidden when viewing the form

Total min/week (days x min)

List types of activities you do (i.e. weightlifting, Pilates, kettle ball, resistance machines, exercise bands, etc.)(Required)

What MOTIVATES you or would motivate you to exercise? Check top three(Required)

Nothing would motivate me

Family or partner

Improve mood

Weight reduction

Control Blood glucose

Body Image

Increase Energy

Reduce blood pressure

Decrease stress

Prevent heart disease

Prevent Bone loss

Improve sleep

Increase self-esteem

Other

Please Specify

Are there any BARRIERS or PROBLEMS that limit exercise? Check all that apply.(Required)

No barriers

Depression

Work Responsibility

Cost

Life Transition Period

Time

Fear

Other

Family Responsibility

Apparel

Energy

Exercise Safety

Do you have any injuries that would make it difficult to exercise?(Required)

Yes

Please explain

Do you have any joint, muscle, or bone problems that might get worse with exercise?(Required)

Yes

Please explain

Do you have any breathing problems while exercising?(Required)

Yes

Please explain

Do you have any balance problems or have had a fall in the last 6 months?(Required)

Yes

Please explain

Do you have any difficulty completing your activities of daily living (i.e. showering, dressing, toileting)?(Required)

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 heart failure

Chronic or unusual fatigue/tiredness

Chest pain/angina

Uncontrolled asthma

Difficulty breathing with activity

Other

Perceived Stress

1=Never 2=Seldom 3=Sometimes 4=Often 5=Always

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

How often have you felt lack of confidence about your ability to handle your personal problems?(Required)

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

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

How do you COPE with stress? Check all that apply.

Meditation

Food (too much, too little)

Gambling

Distraction

Exercise/Physical Activity

Spirituality/Faith

Journaling

Hurting yourself (i.e. cutting, etc.)

Counseling/Psychotherapy

Sex

Massage/Body work

Pet therapy

Socializing with friends or family

Recreational drugs (i.e. marijuana, cocaine, etc.)

Prayer

Other

Art

Television and/or video games

Substance (tobacco, alcohol)

Resilience

When I am under extreme stress

I find a way to learn from my experience.(Required)

I find a way to take action.(Required)

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

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

I meet the goals I set for myself.(Required)

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

I feel motivated to pursue my goals.(Required)

I know I can get through it.(Required)

Mind-Body Connection

I meet the goals I set for myself.(Required)

Do thoughts or feelings affect your physical health?(Required)

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

Are you aware of tension in your body?(Required)

Do you notice how your body changes when angry?(Required)

Do you notice stress in your body?(Required)

Do you notice how your body reacts to emotions?(Required)

Depression

Over the last 2 weeks, how often have you been bothered by the following?

Little interest or pleasure in doing things.(Required)

Feeling down, depressed or hopeless.(Required)

Trouble falling asleep, staying asleep, or sleeping too much.(Required)

Feeling tired or having little energy.(Required)

Poor appetite or overeating.(Required)

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

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

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.(Required)

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

Anxiety

Over the last 2 weeks, how often have you been bothered by the following?

Feeling nervous, anxious, or on edge.(Required)

Not being able to stop or control worrying.(Required)

Worrying too much about different things.(Required)

Trouble relaxing.(Required)

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

Becoming easily annoyed or irritable.(Required)

Purpose and Connection

How often do you agree with the following:

I live a purposeful and meaningful life(Required)

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

I have a source of inner strength and meaning(Required)

I am satisfied with my current belief system(Required)

I have people who care about what happens to me(Required)

I have people who accept me at my worst and best(Required)

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

I get help when I’m sick(Required)

Smoking and Substance History

NICOTINE/TOBACCO (i.e. cigarettes, e-cigarettes, e-cigarettes/vaping, cigars, chew, snuff)

Do you use any of the nicotine products listed above?(Required)

Yes

Do you want to quit using the nicotine/tobacco products?

Yes

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

After 60 minutes

31-60 minutes

6-30 minutes

Within 5 minutes

How many cigarettes do you smoke per day?

10 or less

11-20

21-30

31+

What age did you start smoking?

What is the longest time period you have stayed quit?

What made you start smoking again?

Which of the following people smoke around you? Check all that apply.

Friends

Family

Partner

Co-Workers

Others

Please Specify

How many times have you seriously tried to quit?

For your most recent quit attempt, how long did it last?

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

Check with of the following medications you have used:

Nicotine Patch

Nicotine Gum

Nicotine Lozenge

Wellbutrin/Bupropion Pill

Chantix/ Varenicline Pill

Other

Please Specify

If you used any of the medication listed above, did they help?

Yes

List which ones helped:

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

Yes

Which of the following methods you have used

Self-help

Gradual reduction

Cold turkey

Hypnosis

Acupuncture

Special filters

Vaping/e-cigarettes

Other

Please Specify

Alcohol

Do you drink alcohol?(Required)

Yes

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 handover (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 any of the following substances in the past year?

Recreational drugs (cocaine, heroin, meth, etc.)(Required)

Yes

What level of concern do you have regarding use of the substances

How much substance do you usually use?

Marijuana(Required)

Yes

What level of concern do you have regarding use of the substances

How much substance do you usually use?

Treatment History

Have you ever received treatment for a mental health problem?(Required)

Yes

Have you ever received treatment for drug or alcohol use?(Required)

Yes

Medical Symptom Questionairre (MSQ)

This questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the PAST 30 DAYS. If you are taking after the first time, record your symptoms for the LAST 48 HOURS ONLY.

Point 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(Required)

Constipation(Required)

Bloated feeling(Required)

Belching, passing gas(Required)

Heartburn(Required)

Intestinal/stomach pain(Required)

Nausea or vomiting(Required)

This field is hidden when viewing the form

Digestive Total

Ears

Itchy ears(Required)

Earaches, ear infections(Required)

Drainage from ear(Required)

Ringing in ears, hearing loss(Required)

This field is hidden when viewing the form

Ears Total

Head

Headaches(Required)

Faintness or lightheadedness(Required)

Dizziness(Required)

Insomnia(Required)

This field is hidden when viewing the form

Head Total

Heart

Irregular or skipped heartbeat(Required)

Chest pain(Required)

Rapid or pounding heartbeat(Required)

This field is hidden when viewing the form

Heart Total

Joints/Muscles

Pains or aches in joints(Required)

Arthritis(Required)

Stiffness or limitations of movement(Required)

Pain or aches in muscles(Required)

Feeling of weakness or tiredness(Required)

This field is hidden when viewing the form

Joints Total

Lungs

Chest congestion(Required)

Asthma, bronchitis(Required)

Shortness of breath(Required)

Difficulty breathing(Required)

This field is hidden when viewing the form

Lungs Total

Mind

Poor memory(Required)

Confusion, poor comprehension(Required)

Poor concentration(Required)

Poor physical coordination(Required)

Difficulty making decisions(Required)

Stuttering or stammering(Required)

Learning disabilities(Required)

Slurred speech(Required)

This field is hidden when viewing the form

Mind Total

Emotions

Mood swings(Required)

Anxiety, fear, nervousness(Required)

Anger, irritability, aggressiveness(Required)

Depression(Required)

This field is hidden when viewing the form

Emotional Total

Energy/Activity

Fatigue, sluggishness(Required)

Apathy, lethargy(Required)

Hyperactivity(Required)

Restlessness(Required)

This field is hidden when viewing the form

Energy Total

Eyes

Watery or itchy eyes(Required)

Swollen, reddened or sticky eyelids(Required)

Bags or dark circles under eyes(Required)

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

This field is hidden when viewing the form

Eyes Total

Nose

Stuffy nose(Required)

Sinus problems(Required)

Sneezing attacks(Required)

Excessive mucous formation(Required)

Hay fever(Required)

This field is hidden when viewing the form

Nose Total

Skin

Acne(Required)

Hives, rashes, dry skin(Required)

Hair loss(Required)

Flushing or hot flashes(Required)

Excessive sweating(Required)

This field is hidden when viewing the form

Skin Total

Weight

Binge eating/drinking(Required)

Craving certain foods(Required)

Excessive weight(Required)

Water retention(Required)

Underweight(Required)

Compulsive eating(Required)

This field is hidden when viewing the form

Weight Total

Other

Frequent illness(Required)

Frequent or urgent urination(Required)

Genital itch or discharge(Required)

This field is hidden when viewing the form

Other Total

Total Points

10; Mild Symptoms: 10-50; Moderate Symptoms: 50-100; Severe Symptoms: over 100

Preventive Services

Have you had a physical exam and/or “Wellness” Visit in the past 12 months?(Required)

Yes

I don't know

List date and outcome

Have you had a dental exam and teeth cleaning in the past 12 months?(Required)

Yes

I don't know

List date and outcome

Have you been screened for diabetes with blood work?(Required)

Yes

I don't know

List date and outcome

Have you had your cholesterol, lipids or triglycerides measured?(Required)

Yes

I don't know

List date and outcome

Have you ever had a bone density test to check for osteoporosis?(Required)

Yes

I don't know

List date and outcome

Do you have any balance problems or have had a fall in the last 6 months?(Required)

Yes

I don't know

List date and outcome

Do you have any difficulty completing your activities of daily living (i.e. showering, dressing, toileting)?(Required)

Yes

I don't know

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?(Required)

Yes

I don't know

List date and outcome

Do you have any concerns about your memory?(Required)

Yes

I don't know

List date and outcome

Do you have any trouble with your hearing?(Required)

Yes

I don't know

List date and outcome

Have you had your eyes checked for vision problems?(Required)

Yes

I don't know

List date and outcome

Have you ever had your metabolism or thyroid checked?(Required)

Yes

I don't know

List date and outcome

Have you ever been told that you have a sexually transmitted disease/infection?(Required)

Yes

I don't know

List date and outcome

If you smoke, have you ever had an abdominal ultrasound to check for possible aneurysms?(Required)

Yes

I don't know

List date and outcome

Have you ever received counseling behavioral therapy for any of the following problems?

Weight management or obesity

Nutrition

Smoking or use of other nicotine products

Alcohol use

Which of the following screenings have you completed

Colon cancer screen (stool test or colonoscopy

Breast cancer screen (mammogram)

Cervical cancer screen (PAP smear)

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

82429

Get Started on Your Wellness Journey

To speak to Dr. Gudel and embark on your wellness journey, contact Alabama Lifestyle Medicine by using the contact form or by emailing us.

Email

info@allifestylemed.com

Address

2208 University Blvd Suite 102
Birmingham, AL 35233

Send Us an Email

"*" indicates required fields

Your Name*

Email Address

Message*

6857

A Better Future.
Get More From Lifestyle Medicine.

Quick Links

Services
New Patient
Events
About Us
Your Health

Services
New Patient
Events
About Us
Your Health

Service Hours

Monday : 10:30AM - 5:00PM
Tuesday : 8:00AM - 5:00PM
Wednesday : 8:00AM - 5:00PM
Thursday : 8:00AM - 5:00PM
Friday : 8:00AM - 5:00PM
Saturday - Sunday : By Appointment

Follow us on Social Media

Facebook-f Instagram Linkedin-in