Page1 Roper St. Francis Healthy Lifestyle Program Questionnaire Name Date of Birth Today s Date Who referred you to us? Who is your primary medical doctor? Do you see any other health care providers? If so, whom? MEDICAL DIAGNOSES AND CONDITIONS: Please list all of your medications: (skip if your medicines are current in the electronic medical record system at Roper St. Francis) (list on separate page if needed) Please list all of your Vitamins / Herbs / Supplements: How tall are you? How much do you weigh? Do you have, or have you ever had the following: (Answer yes even if it is controlled with medicine) High Cholesterol High Blood Pressure Heart Attack Congestive Heart Failure Stroke Mini-Stroke Seizures Emphysema / COPD Asthma or Wheezing Stomach Ulcer(s) Yellow Jaundice Colitis (inflammation of the bowel) Thyroid Problems Bleeding Problems Kidney Problems Diabetes If yes, do you have eye problems? Neuropathy Sleep Apnea Osteoporosis Irritable Bowel Syndrome Do you have pain? Yes / No Yes No Explain: If yes, where? If yes, is it all the time, or occasionally?
Page2 PAST SURGICAL HISTORY: Please list all of your past surgeries: Name of Procedure Date Performed by (Doctor) SOCIAL HISTORY: Are you married? Yes / No Do you live alone? Yes / No Spouse s name Who is in household Would you have anyone to help you if need be? Yes / No Employment Highest grade completed in school Have you ever smoked cigarettes or cigars? Current smoker / Previous smoker / Never If previous, when did you quit? If current, how much? How old were you when you started? Do you drink alcohol? Yes / No How many drinks per week /or month Did you used to drink, but quit? Yes / No When did you quit? Do you use any recreational drugs? (e.g. marijuana, cocaine) Yes / No If yes, which? REVIEW OF SYSTEMS: In the last six (6) months: Have you had any fevers lately? Yes No Explain: Has your weight changed at all? Do you get any changes in your vision? Do you get headaches? If so, what causes them? Have you ever had a blood clot in your legs and/or your lungs?
Page3 Do you every get short-term numbness in your hands? Do you have a smoker's cough? Yes No Explain: Can you climb stairs? Do you get short of breath climbing stairs? Do you get short of breath lying down? Do you wake up at night short of breath? Do you ever cough up blood? Do you ever get pressure or aching in your upper body when you exert yourself or get excited? Do you ever get skipped heartbeats or palpitations? Have you ever fainted or passed out? Do you get indigestion? Does food or stomach acid back up in your throat after eating? Do you have chronic diarrhea? Do you get constipated easily? Do you have blood in your stool? Do you have burning or bleeding when you urinate? Do you get up at night to urinate? If so, how often? Do your calves cramp when you walk? Do you have insomnia or trouble sleeping? Do you snore loudly? Do you have sleep apnea? Do you have any implants? (i.e. breast, penile, pacemaker, valves, joint replacements, stents, etc) Do you take insulin? Please indicate: Do you take Aspirin? Do you use an inhaler? Are you currently taking oral contraceptives? Do you have any other medical problems that you would like to share with us?
Page4 ALLERGIES: Are you allergic to, or intolerant of any medications? (Please list) Do you have a latex or adhesive tape allergy? Yes / No If yes, what happens? Are you allergic to IV / Iodine dyes? Yes / No Are you allergic to shellfish? Yes / No Are you allergic to, or intolerant of any other foods? (please list) FAMILY HISTORY: Does anyone in your biological family (parents, grandparents, aunts, uncles, brothers, and sisters) have or did they have any of the following? If so, who? Heart Disease or Heart Bypass Surgery? Diabetes? Cancer? Stroke? Carotid Artery Surgery? (arteries of the neck) Abdominal Aortic Aneurysm? Any other disease(s) that run in your family? NUTRITION HISTORY: Who buys groceries? How often? Where do you eat your meals? Who cooks meals? Do you read food labels? If yes, explain Please list all the beverages you drink and how much (tea, milk, juice, sodas, etc.) Please list the snack foods you eat: When during the day are you hungriest? Do you ever feel that your eating is out of control? How often do you eat at a restaurant? Where? Have there been any recent changes to your eating?
Page5 Do you follow any certain nutrition guidelines? (e.g. avoid gluten, artificial sweeteners, choose organic) What is the most you ve ever weighed? When was that? What would you like to weigh? What is attractive about this weight to you? Have you ever followed a specialized diet plan before? If so, describe EXERCISE HISTORY: What are your exercise-related goals? Check all that apply: Appearance Cardiovascular Fat Reduction Flexibility Health Muscle Definition Muscular Endurance Muscular Size Strength Power Self Esteem Speed Sports Stress Toning Weight Posture Other: How are you going to feel when you ve achieved these goals? List any other specific fitness goals (e.g. run 5K, get back into your old jeans, play soccer with your kids) Rate your overall activity level: (circle one) Sedentary Moderately Active Active Very Active What exercise, if any, do you currently do? What exercise, if any, have you done in the past? How long ago? If you have an existing resistance training regimen, please list the exercises you have regularly performed in the past month: What is your current cardiovascular fitness level, or your ability to perform aerobic exercise like cycling, brisk walking, jogging? (circle one) Very low Fair Average Good Excellent How would you rate your experience with exercise? What (if anything) intimidates you about exercise? (Check all that apply) I feel intimidated or embarrassed in an exercise setting Upcoming holidays or planned vacation may make it difficult to fit in exercise
Page6 I travel extensively for work or fun Work demands may make it difficult to exercise I might get frustrated if I don t see results right away Family obligations may make it difficult to exercise My family or friends may not support my attempts to exercise Exercise is not enjoyable or fun for me I get bored easily when I exercise It s hard for me to exercise when I m tired or fatigued I may forget or lose track of my goal I may have to exercise alone The exercise setting available to me may not meet my needs I don t enjoy exercising in bad weather (rainy, hot, humid, cold, snow) I have no personal obstacles in adhering to an exercise program Below, please tell us about some experience(s) in your life where you have worked hard for a goal and achieved it. Perhaps it was an athletic event, or maybe you learned a new language, etc. And then, how did you feel once you accomplished it. Please be as specific as you can. COMMUNICATION May we contact you by email to send appointment reminders, newsletters? If yes, please provide email address: What is the BEST phone number for us to reach you? If this is a cell phone, may we send you a text message? If you would you like an invitation to join our closed group Facebook page, list the name would we search for: Please list two people we could call in case of emergency: Name Relationship Home Work/Cell I agree that the information given on this form is true based on my current knowledge. Signature Date