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Center for Lifestyle MedicineInitial Assessment259 East Erie Street, Suite 1600 312.695.2300 312.926.6068 (fax)Name:Date:BACKGROUND QUESTIONSPreferred phone:E-mail:Occupation:Work hours:Marital Status (please check):DivorcedSingleMarriedWidowPartneredPlease list names of the people in your household and their relationship to you:Do you own a family dog?YesNoWhat is the highest level of education completed?What prompted you to seek services at this time?What are your personal goals we can help you achieve?OVERALL HEALTH QUESTIONSPrimary care provider: Phone:Address:When was your last physical exam? When did you last have blood tests?How would you rate your health? (please check):ExcellentGoodFairPoorHeight: Weight:Continued page 1
Center for Lifestyle Medicine Initial Assessment (continued)PAST MEDICAL HISTORY Mark (x) all that apply:Acid Reflux (GERD)Diabetes (Type 2)Kidney DiseaseAnemiaEmphysema/Chronic BronchitisLiver DiseaseAnorexiaEpilepsy/Seizure DisorderMigrainesAnxietyFatty Liver DiseaseMultiple SclerosisArthritisGallbladder Disease/StonesObsessive Compulsive DisorderAsthma/Lung ProblemGlaucomaOsteoporosis/peniaAttention Deficit DisorderGoutBipolar DisorderHeart Disease/Heart AttackPolycystic Ovarian Syndrome(PCOS)Bleeding DisordersHeart MurmurPacemakerBlood clot/DVTHepatitisProstate ProblemBulimiaHigh Blood Pressure/HypertensionSickle Cell DiseaseCancerCeliac DiseaseHigh CholesterolStrokeCongestive Heart FailureHIV DiseaseThyroid DiseaseDrug/Alcohol DependencyIrregular Menstrual PeriodsTuberculosisDepressionImpaired Fasting Glucose/Pre-DiabetesUlcer DiseaseDiabetes (Type 1)Sleep ApneaOtherREVIEW OF SYSTEMS Mark (x) all that WeaknessExcessive shortness of breathCoughingWheezingSnoringChest painAnkle or feet swellingIrregular heart beatVaricose veinsLow energy levelDaytime sleepinessDisturbed onAbdominal painChange in bowel habitsHemorrhoidsRectal bleedingDifficulty urinatingRecurrent urinary infectionsUrinary incontinenceInfertilityInability to empty bladder fullyAbnormal menstrual periodSexual problemsFrequent urinationContinued page 2
Center for Lifestyle Medicine Initial Assessment (continued)REVIEW OF SYSTEMS (continued) Mark (x) all that apply:MUSCULOSKELETALBack painMuscle crampsJoint painMuscle weaknessDifficulty ve thirstCold/heat intoleranceExcessive/increased urinationBlurry glingInfection (boils, ulcers, etc)Abnormal bruisingChronic rashesExcessive hair growth (females)AcneChanges in skin colorLack of interest in doing thingsAnxiousFeel down, depressed or hopelessHistory of physical violence/abuseAverage hours of sleep each night Is sleep refreshing?How would you rate your stress level? low1234YesNo5 highHow do you cope with daily stressors?Are you currently seeing a mental health professional?YesNoIf yes, please provide name and contact information:List all previous surgeries with date:List your current medications and dosages. Include any vitamins and supplements:1.5.2.6.3.7.4.8.Do you have any allergies to medications?Continued page 3
Center for Lifestyle Medicine Initial Assessment (continued)Preventive care screenings and diagnostic tests you have had (please check and provide the date):Sigmoidoscopy/ColonoscopyPap SmearCardiac Stress TestMammogramBone DensityProstate/Testicular ExamTobacco history (please check):Never SmokedPast SmokerCurrent SmokerAlcohol history (please check):Do Not DrinkCurrently Drink drinks per weekRecreational drug use (please check):NeverPast UserPresent UserFAMILY HEALTH HISTORY:RELATIONAGEMEDICAL CONDITIONSOVERWEIGHTOR OBESE?AGE ATDEATHFatherMotherSiblingsSpouseChildrenContinued page 4
Center for Lifestyle Medicine Initial Assessment (continued)NUTRITION QUESTIONNAIREWhat one or two things would you like to change about your diet?Do you read food labels? If yes, what do you look for?How confident are you about the amount of current nutrition knowledge you have? low1How confident are you about your ability to apply the nutrition knowledge you have? low21325 high4345 highDo you have any food allergies?Do you follow any special diet or dietary restrictions?When and what do you usually eat over the course of a typical day? (Please list in table below):MEALTIMEFOODS EATENBreakfastSnackLunchSnackDinnerSnackWhat do you drink throughout the day?How many meals per week do you eat in restaurants/order takeout?Do you eat much more rapidly than others?YesNoDo you eat until feeling uncomfortably full?YesNoDo you eat large amounts of food when you are not feeling physically hungry?YesNoDo you feel disgusted with oneself, depressed, or very guilty after overeating?YesNoDo you eat alone because of being embarrassed by how much you are eating?YesNoDo you have a history of an eating disorder? (If yes, please check):Compulsive OvereatingBinge Eating DisorderAnorexiaDo you feel that you have a food addiction (loss of control over food intake)?BulimiaYesNoContinued page 5
Center for Lifestyle Medicine Initial Assessment (continued)PHYSICAL ACTIVITY QUESTIONNAIREWhat is the most active thing you do in an average day?What, if any, regular exercise do you participate in and how often?In general, how much do you enjoy doing physical activity?low enjoyment1235 high enjoyment4What makes it difficult for you to exercise?Do you know any other reason why you should not do physical activity?YesNoWhen you exercise or exert yourself, do you have any of the following? (please check if yes)Shortness of breathChest pain or pressurePain in your calvesWEIGHT HISTORYWhat was your lowest body weight as an adult? lbs. At what age?What was your highest body weight as an adult? lbs. At what age?Have you previously participated in a commercial or professional weight loss program?YesNo(If yes, please check all programs):Weight WatchersJenny CraigNutriSystemWeight Loss MedicationWomen’s Workout WorldVery Low Calorie DietOther(name of medication)Have you previously seen a Registered Dietitian (RD)?YesNoHave you ever had weight loss surgery? If so, which one and when?What is the maximum amount of weight you’ve lost in the past? lbs.What are the biggest challenges you face in losing weight/maintaining weight loss?How important is it for you to make lifestyle changes?very important12345 not importantHow confident are you in your ability to make lifestyle changes?very confident12345 not confidentContinued page 6
Center for Lifestyle Medicine Initial Assessment (continued)Graphing your weight gainBelow are examples of typical weight gain patterns according to life events.TIMETIMEUsing the examples as a reference, please graph your weight gain. Mark life events and diet attempts that may havecontributed to your current weight.Weight(pounds)Time (age or year)Continued page 7-----Illness orphysical injuryLiving awayfrom self diet-Initiatedself e--Death infamilyInciting Event Weight Gain-Weight Cycling or “Yo-Yo” Weight Gain-Stressfuljob---WEIGHTProgressive (or Ratcheting) Weight Gain
Center for Lifestyle Medicine Initial Assessment (continued)SIX-FACTOR TRAIT QUESTIONNAIRE (6-FTQ) Please check your level of agreement to all statements:Don’t agreeat allAgreea littleAgreeStronglyagreeCONVENIENT DINER1.I rarely take the time to plan my meals.01232.A lot of my meals are eaten in restaurants or taken out.01233.Most foods I eat are convenient, ready- made, packaged,frozen or microwavable.01234.I eat a fast-food meal on most days of the week.01235.I do not have consistent meal patterns from one day to the next.0123Sub scoreFAST PACER6.My fast-paced life leaves me feeling drained and scattered.01237.I feel like I’m juggling too many things at once.01238.I usually take care of everyone else and put myself at thebottom of my to-do list.01239.My hectic schedule makes it hard for me to focus on my health.0123Sub scoreEASILY ENTICED EATER10. I have difficulty controlling my portion sizes.012311. I often eat out of habit, not because I am hungry.012312. When I’m stressed, lonely, anxious or depressed, I turnto food for comfort.012313. If there is food around me, I’ll probably eat it.012314. I snack throughout the day, hungry or not.012315. I will eat until I’m too full – and may even eat more.0123Sub scoreContinued page 8
Center for Lifestyle Medicine Initial Assessment (continued)SIX-FACTOR TRAIT QUESTIONNAIRE (6-FTQ) Please check your level of agreement to all statements:Don’t agreeat allAgreea littleAgreeStronglyagreeEXERCISE STRUGGLER16. Of all things being physically active has never beenone of my priorities.012317. I don’t exercise because frankly I don’t like it.012318. I never got “into” exercising because I am not sure where to start.012319. I have difficulty exercising.0123Sub scoreSELF-CRITIC20. I measure my self-worth by the numbers on the bathroom scale.012321. I focus on the things I don’t like about my body.012322. I make a habit of saying bad things about myself.012323. I avoid social situations because of my weight.0123Sub scoreALL-OR-NOTHING DOER24. I approach my weight loss like it’s just another project witha clear beginning and end.012325. I’m either on or off my diet – there’s no middle ground with me.012326. When I’m trying to lose weight, I give 100% of my effort butthis is hard to sustain.012327. I am all or nothing when it comes to dieting or exercisingto lose weight.0123Sub score17-569/0317 2017 Northwestern Medicine. All rights reserved.
Center for Lifestyle Medicine Initial Assessment (continued) SIX-FACTOR TRAIT QUESTIONNAIRE (6-FTQ) Please check your level of agreement to all statements: Don’t agree Agree Strongly at all a little Agree agree CON
