Lifestyle Docs - Publicforms

Available Forms

I. New Patient Registration Form, Required II Uninsured New Patient Registration Form III. Patient Medical History, Required IV. Request an Appointment IV. Review of Systems IX. Spanish Patient Medical History, Required V. Lifestyle History, Optional V. Nutrition & Dietary Habits, Optional VI. Detailed Autoimmune Disease History, Optional VI. Detailed Diabetes History, Optional VI. Detailed Digestive Health History, Optional VI. Detailed Hypertension History Optional VI. Detailed Weight History, Optional VII. Spanish New Patient Registration Form VII. Spanish Uninsured New Patient Registration Form

V. Lifestyle History, Optional

Name *

Please, enter your first name followed by last name

Sex *

Male

Female

Date of Birth *

Sleep Habits

How many hours do you sleep on a typical weekday? *

7 - 9 hours

6-7 hours

5-6 hours

Less than 5 hours

More than 9 hours

How many hours do you sleep on a typical weekend?

7 - 9 hours

6-7 hours

5-6 hours

Less than 5 hours

More than 9 hours

How do you rate your sleep quality in general? *

High quality, I sleep sound through the night

Good quality, I only wake to use the bathroom or if theres a loud noise

Okay quality, I wake one or two times a night

Poor quality, I have trouble staying asleep and wake up in the middle of the night

Very poor quality, I have trouble falling asleep, staying asleep, wake up multiple times and feel exhausted in in the morning

What time do you go to sleep on weekdays? Weekends?

How important do you think sleep is in relation to health? *

Very important

Somewhat important

Not important

Activity Level

What kind of work do you do? *

Sedentary, at a desk

On my feet periodically throughout the day

On my feet periodically and lifting throughout the day

On my feet the entire shift

Please select all that apply

Do you have any physical limitations? *

How many hours of TV do you watch in a day? *

How many hours do you spend on social media, online shopping, or surfing the web? *

Do you engage in physical activity? How many times per week? *

Please answer y/n, # of times per week

If no, are you willing to begin exercising? *

Yes

Are there any exercises you are interested in trying?

How much time can you devote to exercise on a typical day?

Caffeine, Alcohol and other substances

How much caffeine do you consume in a day? *

No caffeine

1-2 cups of coffee, tea, or other caffeinated drinks(e.g. energy drinks)

3-5 cups of tea, or other caffeinated drinks(e.g. energy drinks)

>6 cups of tea, or other caffeinated drinks(e.g. energy drinks)

Please list types of caffeine consumed and when

Examples: energy drinks, coffee, tea, etc

Please select which best describes your alcohol consumption

I do not consume alcohol

I consume alcohol once a month or less

I consume alcohol on the weekends only

I consume alcohol casually with meals or in the evenings

I consume alcohol daily to take the edge off

Please select all that apply

If yes, please list what alcoholic beverages you consume

ie. wine, beer, liquor, mixed drinks, liqueur

How many of each beverage do you consume in a week?

Beer

1-3

4-6

7 or more

Wine

1-3

4-6

7 or more

Liquor or other alcohol

1-3

4-6

7 or more

Do you now or have you ever had a problem or addiction to alcohol? *

If no, n/a. If yes, please list when and how long.

Are you currently using any street drugs? *

Yes

Do you now or have you ever had a problem or addiction to street drugs or prescription drugs?

Please, write Yes or No. If yes, please list when and how long.

Emotional Health

Please indicate if you've had any of the following experiences in the last three months?

Feelings of being down or depressed? *

Yes

Consistent or excessive worry about multiple things?

Yes

Felt very nervous or anxious or suddleny experienced physical symptoms such as heart racing, sweaty palms?

Yes

Avoided social situations out of fear of what others may think or say about you?

Yes

Found yourself preoccupied with food, weight, or body image?

Yes

Felt concerned about your use of alcohol, medication or drugs?

Yes

What best describes your emotional state? *

Happy

Okay

Not happy

How does your current appearance make you feel? *

Happy

Okay

Not happy

How does your current weight make you feel? *

Satisfied

Unsatisfied

Concerned

Which best describes you? *

I care a lot about what others think of me

I care somewhat what others think of me

I don't care what others think of me

Stress Management

Do you generally cope with everyday stressors at home and work with ease? *

Yes

Do you practice any of the following anti stress techniques? *

Exercise

Conscious Relaxation

Breathing Techniques

Yoga/Meditation

Hobbies that reduce stress

Listen to music

Spending time in nature/gardening

Prayer/church activities

None

Please select all that apply to your current stress management habits.

How important do you think managing stress is for overall health?

Very important

Somewhat important

Not very important

Community & Support

Which best describes your relationship status? *

Married

Single

In a committed relationship

Other

Which best describes your satisfaction with your relationship status?

Happy

Neutral

Unhappy

Which best describes your significant others support in your life efforts?

My significant other will be helpful and supportive in my health efforts

My significant other is generally neutral in my health efforts

My significant other generally causes much difficulty in my health efforts

Which best describes your closest friends and family support?

My closest friends/family will be helpful and supportive in my health efforts

My closest friends/family are generally neutral in my health efforts

My closest friends/family generally cause much difficulty in my health efforts

In what area of your life do you think will be the most challenging on your health efforts?

Home when I'm alone

Home when I'm with family

Socially with family

Socially with friends

At work with colleagues

Do you think you would benefit from additional support from Lifestyle Docs?

Yes

Would you be interested in joining a support group within our practice?

Yes

* Required field