health history questionnaire: general nutrition ......☐ anxiety disorder ☐ diabetes –...

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HEALTH HISTORY QUESTIONNAIRE:GENERAL NUTRITION & BEHAVIORAL HEALTHThe personal information contained in this questionnaire will be kept confidential. The completed questionnaire is part of your patient file. Please fill this form out completely to make the most of your time with your providers.

DEMOGRAPHIC INFORMATION:

Name: ______________________________________

Address: ____________________________________

Email address: _______________________________

Home Phone: ________________________________

Cell phone: ___________________________________

Work phone: _________________________________

Physician: ____________________________________

Occupation: __________________________________

Gender: M F Age: ___________ Birth date: _____________

Race: _________________________________________________ Hispanic or Latino Ethnicity? Y N

Emergency Contact: ____________________________________

Relationship to you: ____________________________________

Contact’s phone number: ________________________________

Marital status: Single Married Divorced

Life Partner Widow/Widower Legally Separated

Employer: ___________________________________________

Employment Status: Full time Part time Not employed Retired Disabled Active Military Duty

Self Employed Student: Part/Full time

MEDICAL HISTORY: ☐ Anorexia ☐ Diabetes ‐ Insulin ☐ Hiatal Hernia ☐ Pacemaker *

☐ Anxiety Disorder ☐ Diabetes – Non‐Insulin ☐ HIV or AIDS ☐ Polycystic Ovarian

☐ Arthritis ☐ Dialysis – End Stage ☐ High Cholesterol Syndrome (PCOS)

☐ Asthma Kidney Disease ☐ High Blood Pressure ☐ Pulmonary Embolism

☐ Bipolar Disorder ☐ Diverticulitis/Diverticulosis ☐ Hyperthyroid (high) ☐ Reflux Disease

☐ Bleeding Disorder ☐ Depression ☐ Hypothyroid (low) ☐ Schizophrenia

☐ Blood Clots (or DVT) ☐ Eating Disorder ☐ Kidney Disease ☐ Sleep Apnea

☐ Bulimia ☐ Fibromyalgia ☐ Kidney Stones ☐ Stroke

☐ Cancer ______________ ☐ Gout ☐ Leg/Foot Ulcers ☐ Tuberculosis

☐ Coronary Artery Disease ☐ Heart Attack ☐ Liver Disease ☐ Ulcers

☐ Heart Murmur ☐ Osteoporosis ☐ Other ____________

Please list any surgeries you have had: __________________________________________________________________

MENSTRUATION HISTORY: Mark any that apply: I am male (skip to Weight History) I am pregnant I am breastfeeding

I have had a hysterectomy I am post-menopausal

Age of menses (first period): _____________ Date of last period: _______________

Are your periods regular/monthly? Y N If no please explain: __________________________________________

Have you ever skipped periods for 3 months or more? Y N If yes, when and for how long did you go without a

period? ___________________________________________________________________________________________

Are you on birth control? Y N Type: ____________________ Reason for birth control: _________________________

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WEIGHT HISTORY:

Height: ________ Weight: __________ Ideal/goal weight: __________ Why this weight? ________________________

How often do you weigh yourself? _________________ Weight maintained for ≥ 6 months: ________________

Highest adult weight and age: ____________________ Lowest adult weight and age: _____________________

How or why? __________________________________ How or why? __________________________________

Are you currently on a diet plan? Y N If yes, describe ____________________________________________________

Do you track your diet and exercise? Y N How? ______________________________________________________

Please list any food allergies or intolerances: _____________________________________________________________

Are you considering weight loss surgery? Y N If yes, which surgery are you considering? _______________________

Which surgeon are you considering? _____________________________________________________________

WHAT ATTEMPTS HAVE YOU MADE TO LOSE WEIGHT?

Past Diet Attempts: ☐ NutriSystem Other Weight Loss Attempts: Past Exercise Attempts:

☐ American Heart Association ☐ Paleo diet ☐Acupuncture ☐ Aerobics or other classes diet

☐ Quick Weight Loss Center ☐Shots ☐ Bicycling ☐ Atkins

☐ Slim Fast ☐Over-the-Counter ☐ Curves or circuit training ☐ Diet Center

☐ Slim for Life Medications: ☐ Exercise videos

☐ Fad diets

☐ Fasting ☐ South Beach

☐ Weight Watchers

____________________

☐Prescription Medications: ☐ Silver Sneakers

☐ Gym ☐ HCG diet

☐ Hypnosis ☐ Other self-imposed diets

☐ ____________________

____________________

☐Supplements: ______________

☐ Jogging

☐ Walking ☐ Jenny Craig

☐ ____________________ ☐Wired Jaw ☐ Weight Lifting ☐ Juicing

☐ ____________________ ☐Weight Loss Surgery ☐ Working with a trainer ☐ LA Weight Loss

☐___________________ ☐ ____________________ ☐ MD Diet

EATING HABITS

Who prepares meals? ________________ Plans meals: ___________________ Buys food: ________________________

Where are meals eaten in the home? standing in kitchen dining room table couch bed _____________

Whom do you eat your meals with? _____________________________________________________________________

What are some barriers you face eating more home cooked meals?___________________________________________

Do you “graze” throughout the day? Y N If yes, on what kinds of foods? ______________________________________

Do you go on eating binges for no apparent reason? Never Seldom Occasionally Constantly

Do you have feelings of guilt and remorse about food and dieting? Never Seldom Occasionally Constantly

Do you give too much thought and time to food? Never Seldom Occasionally Constantly

Do you use laxatives, diuretics, diet pills, etc. to manage your weight? Never Seldom Occasionally Constantly

Weight Treatment Center at St; Mark’s Hospital 1160 East 3900 South Suite G100, Salt Lake City, Utah 84124 801-268-7479

Other

Other Other

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Do you purge (vomit) to manage your weight? Never Seldom Occasionally Constantly

Do you avoid social situations with food? Never Seldom Occasionally Constantly

Do you avoid social/physical activities due to your weight or size? Never Seldom Occasionally Constantly

Do you consume ≥ 50% of your calories for the day after 7 pm? Never Seldom Occasionally Constantly

USUAL HABITS:

Beverages You Drink:

☐ Coffee _______________ cup/day

☐ Herbal tea ____________ cup/day

☐ Black tea _____________ cup/day

☐ Fruit juice ____________ cup/day

☐ Alcohol

Type _______________________

How much __________________

How often___________________

☐ Regular soda ___________ oz/day

☐ Other sweetened beverages:

Type: _______________________

How much _____________ oz/day

☐ Water _________________oz/day

☐ Diet soda ______________oz/day

☐ Other sugar-free beverages:

Type: _______________________

How much _____________ oz/day

☐ Energy drinks ___________oz/day

☐ Milk _________________cup/day

☐ Other: ______________________

Meal Habits

☐ #Meals per day ______________

☐ # Snacks per day ______________

☐ #Meals eaten out of the home per

week: ______________________

☐ # of Fast Food Meals eaten per

week: ______________________

☐ Do you snack or “graze”

frequently throughout the day?

o If yes, on which foods?

o _________________________

o _________________________

o _________________________

o _________________________

o _________________________

o _________________________

o _________________________

Physical Activity:

What is your activity level?

Sedentary Light Moderate Very Active

How many days out of 7? __________

What types of activity/duration?

_______________________________

_______________________________

_______________________________

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How often do you do resistance

training (i.e. weights)? ____________

What types of training/duration?

_______________________________

_______________________________

_______________________________

List any barriers that limit your

activity.

_____________________________

_____________________________

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ONE DAY FOOD AND BEVERAGE INTAKE Please record everything you eat or drink for one day before your appointment. Do the best you can! Date: ______________ Was this a typical day for you? Y N

Meal Time Foods and Beverages Amount

consumed Mood, thoughts,

events, etc

Breakfast 10:00 am Instant oatmeal 1% skim milk Blueberries Orange juice EXAMPLE

2 packets ½ cup ½ cup ½ cup

Woke up late and had to eat fast. Felt bloated.

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Exercise

What did you do? How long did you do it?


___________________ ____ ______________ ______________________________________

___________________ ____ ______________ _______________________________________

___________________ ____ ______________ _______________________________________

____________________ ____ ______________ _______________________________________

____________________ ____ ______________ _______________________________________

_____________ _______ ____ ______________ _______________________________________

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BEHAVIORAL/PSYCHIATRIC HISTORY: Have you been diagnosed with a mental illness? Y N If so please specify: ____________________________________

Are you currently taking medications for a mental illness? Y N If no, why? ____________________________________ Have you ever sought professional help for emotional problems? Y N If yes, please specify below.

Problem Year Duration Therapist, Doctor or Treatment Center Name:

Have you ever been hospitalized for a mental illness? Y N If yes, please specify below.

Where Year Duration For what reason

How many people currently live in the home? ________

If you are currently involved in an intimate relationship (significant other), please answer the following questions.

What is this person’s attitude toward your efforts to make changes in your life? (check one)

Strongly supports my efforts

Supports my efforts

Neutral

Opposes my efforts

Strongly opposes my efforts

Please describe briefly what this person does to either help or hinder you.

Are there other people (family/ friends) who will support your efforts? Y N

If yes, who are these people? __________________________________________________________________________

TOBACCO, ALCOHOL, AND DRUG USE: Do you currently smoke or have you quit smoking in the last 6 months? Y N Quit date: ___________________

I smoke (#) _____________cigarettes per day/week (circle one) for _______ years.

I used to smoke (#) _______cigarettes per day/week (circle one) for (#) _____ years.

Do you chew tobacco? Y N. If yes, how much and for how many years? _____

Do you use an e-cig or other tobacco products? Y N. If yes, how much and for how many years? _____

Would you like information to help you quit? YES NO

Have you used drugs (illegal or abused your own or someone else’s prescription drugs) in the last 6 months? Y N

If yes, list which drugs have you used, amount, and frequency of use. ____________________________________

Are you struggling with a substance abuse or alcohol addiction? Y N

Have you sought treatment for alcohol or substance abuse? Y N

Are you currently in treatment and if so where? ____________________________________________________


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Stress:

Hours of sleep average per night? __________ Is your sleep restful? __________________________________________

On a scale from 1 (low stress) to 5 (high stress), how do you rate your daily stress level? __________________________

How do you cope with stress in your daily life? ____________________________________________________________

On a scale of 1 (not ready) to 5 (very ready), how ready are you to make lifestyle changes? ________________________

On a scale of 1 (not confident) to 5 (very confident), how confident are you to make lifestyle changes? _______________

Please indicate if you are currently experiencing any stress in your life related to the following events. Complete each

item by circling yes or no and use the provided space to describe the situation.

Work: Y N _______________________________________

Health: Y N _______________________________________

Relationship with spouse/significant other: Y N _______________________________________

Activities related to your children: Y N _______________________________________

Activities related to your parents: Y N _______________________________________

Legal/financial trouble Y N _______________________________________

School: Y N _______________________________________

Moving: Y N _______________________________________

Other (please specify): ____________________ Y N _______________________________________

Are you planning any life changes (e.g., new job, moving, relationship changes, etc.) during the next 6 months? Y N If yes, please describe: _______________________________________________________________________________

What other steps have you taken in the past that have helped you to become healthier that is not already mentioned?

What challenges have prevented you from making and/or maintaining lifestyle and weight changes?

What are your motivations for meeting with a dietitian? Anything else we should know to help you succeed?

Please look over this form to be sure you answered every question. Do not leave any items blank.


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My Medication Record

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health history questionnaire: general nutrition ......☐ anxiety disorder ☐ diabetes –...

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