Best Life Initial Assessment Packet

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Best LifeInitial AssessmentPacketUpdated: May 19,20141

Department of PsychiatryPATIENT INFORMATIONFMNAME IN FULLAGEDATE OF BIRTHTODAY’S DATEADDRESSCITYCOUNTYSTATEZIP CODEHOME TELEPHONE NUMBERWORK TELEPHONE NUMBERCELL NUMBERMARITAL STATUSOCCUPATIONEMPLOYERREASON FOR APPOINTMENTREFERRED BY /HOW DID YOU HEAR ABOUT USCOMPLETE IF PATIENT IS A MINORMOTHER’S NAMEFATHER’S NAMECUSTODYBoth ParentsLIVES WITHMotherFatherPARENT’S/CONTACT’STELEPHONE NUMBEROtherNAMEADDRESSBoth ParentsMotherTELEPHONE NUMBER FOREMERGENCY CONTACTOtherRELATIONSHIP TO PATIENTHOME TELEPHONE NUMBERWORK TELEPHONE NUMBERCITYSTATEZIP CODECONTACTSPRIMARY CARE PHYSICIANSPECIALTYLAST APPOINTMENTCITYSTATEPHONE NUMBERPSYCHIATRISTCITYFatherLAST APPOINTMENTSTATEHOW LONG HAVE THEYTREATED YOU?HOW LONG HAVE THEYTREATED YOU?PHONE NUMBERTHERAPISTLAST APPOINTMENTCITYSTATEHOW OFTEN DO YOU MEET?DO YOU FIND IT HELPFUL?IF NOT CURRENTLY IN THERAPY, HAVE YOU BEEN IN THE PAST?IF SO, WAS IT HELPFUL?HOW LONG HAVE THEYTREATED YOU?PHONE NUMBERNUTRITION THERAPISTLAST APPOINTMENTCITYSTATEPHONE NUMBERHOW OFTEN DO YOU MEET?DO YOU FIND IT HELPFUL?IF NOT CURRENTLY IN THERAPY, HAVE YOU BEEN IN THE PAST?IF SO, WAS IT HELPFUL?2HOW LONG HAVE THEYTREATED YOU?

Medical/Psychology HistoryMEDICAL AND MENTAL HEALTH PROBLEMS for which you are being treated:PROBLEMDOCTORHOW TREATED1.2.3.4.5.6.7.8.SURGERIES you have had:SURGERYWHEN1.2.3.4.5.6.7.8.MEDICATIONS and over-the-counter pills you are taking:NAME OF MEDICATIONDOSAGEHOW OFTEN TAKEN1.2.3.4.5.6.7.8.ALLERGIES:Are you allergic to any medications?YesDRUGNoPROBLEM1.2.3.4.5.Do you have any food allergies?YesNoIf so please list:3If so please list:

Current Medical ConcernsCheck all that applyCardiovascularHeart problemsRequiring medication?Chest painsRacing heart/skippingHigh blood pressureRequiring medication?Chest tightnessShortness of breathHigh cholesterolRequiring medication?High triglycerides Requiring medication?Feel tired all the timeDiabetesDiabetes - Type I or II Requiring medication?Pre-diabeticElevated blood sugar?Gestational diabetesAge of Diagnosis?Hypoglycemia (low blood sugarThyroid nalGallbladder problemsRemoved?Stomach ulcersRequiring medication?Heartburn Daily?Nocturnal?RegurgitationRequiring medication?DiarrheaRequiring medication?ConstipationRequiring medication?RespiratoryAsthmaLast attack?Bronchitis # of times in past 2 yearsIs it recurring?Pneumonia # of times in past 2 yearsBlood clots in lungsSmokerStarting age?When did you stop?Smokeless tobaccoSnoreWake up gasping or with a smothered feelingMusculoskeletalLocationMildModerate SevereHip painKnee painAnkle painFeet painBack painNeck painArthritisFemales Only - Menstrual HistoryAre you currently menstruating?YesNoHave never menstruatedDate of last menstrual cycleAre your periods regular?Any difficulty conceiving?Are you taking birth control pills/patches/injections or utilizing another form of birth control to preventpregnancy? If so, what?Are you currently breast feeding?How many times have you been pregnant? How did you deliver?4

Family and Social HistoryDid you ever experience any of the following during your childhood or adolescence?FAMILY:ABUSE/TRAUMA:Death of a parentPhysical abuseDeath of other loved one or close friendSexual abuseLife threatening illness in immediate familyVerbal/Emotional abuseSeparation from a parent for a monthNeglectParent’s separation/divorceRapeLoss of home through natural disasterOther traumatic eventIf yes, please explain:Family financial problemsParent with substance abuse problemEDUCATION:Significant conflict with parentsWhat’s the farthest you’ve gone in school?Foster careWhat grades did you make in school?What is your occupation/career? How long have you worked in this capacity?What, if any, legal problems have you had?What stresses are in your life now?What is your current living situation?Describe your social support system:Are you currently married?YesNoHow many children do you have?How many times have you been married?Their ages:Have you ever been hospitalized for mental illness or substance abuse: yes noIf yes, please explain:Please check which substances you have used in your lifetime:CurrentAlcoholTobaccoMarijuana/Spice/ K2Cocaine/ crackHeroinGHBEcstasyLSD or MushroomsPCPKetamine (special “K”)PastDate of lastuse:CurrentPastDate oflast ivan,Klonopin, Xanax)Opiates/pain pillsSoma/muscle relaxantsUltram/tramadolInhalantsNitrous oxideIV Drugs:Other:Please answer the following:How many drinks do you need to feel a buzz/”high”?Are you or others concerned with how much you drink?Do you need a drink in the morning?Do you have periods of time you don’t remember associated with your drinking?Have you ever blacked out from drinking?Have you tried to cut down your drinking?5YesNo

Weight & Diet History:How do you feel about your body?:Describe in your words how obesity is affecting your life:What is your primary motivation for losing weight?What do you think is the primary reason for your weight gain?injurylack of exercise pregnancypoor eating habits hereditymarriagesmoking cessation divorcefood addictionovereatingstressWhat is your highest weight?lbswhen?What is your lowest weight?lbswhen?What is your desired weight range? lbs to lbsActivity/Exercise History:What is your regular activity level:Minimally active: (very sedentary, rarely leave the house)Somewhat active: (light housework, gardening, walking on errands orwhile working)Moderately active: (exercise 1-3 times a week, walking for exercise)Very active: (exercise 3 or more times a week, e.g. aerobics, running,swimming, weight training, cycling)Extremely active: (daily vigorous exercise)What are your favorite activities or exercises?What physical activities are you currently engaged in?Meals:How many meals per day do you eat?1 meal 1-2 meals 2 meals 2-3 meals 3 meals 3 or more mealsDo you skip meals? yes noIf yes, what meal(s) do you usually skip?How many days a week do you skip this meal?Do you skip meals to control your weight?6

Are your meals:large portions extra large portions high fat high in carbs high in sugarHow often do you snack:a.m. snack p.m. snack evening snack snack between all mealsWhat are your favorite snacks?What beverages do you drink?waterwhole milkskim milkregular sodadecaf coffeeregular teasweet teaunsweetened tea2% milkdiet sodadecaf tea1%milkregular coffeejuiceHow often do you eat out?Do you eat rapidly? yes noDo you eat in secret or hide food? yes noIf yes, why?Do you consider yourself a binge eater? yes noIf yes, what do your consume during a binge?If yes, how often do you binge?If yes, do you feel out of control when you binge? yes noDo you eat large amounts of food when you’re not hungry? yes noDo you eat more than you intended to at one sitting? yes noDo you feel guilty after you have eaten? yes noIf yes, why?Do you feel like you’re an emotional eater? yes noIf so, please describe:Have you ever used laxatives to assist with weight loss? yes noHave you ever used diuretics for weight loss? yes noDo you induce vomiting? yes no If yes, how many times a day?Do you exercise excessively to compensate for food you have eaten? yes noAbout how many calories do you think you eat a day?How hungry do you let yourself get:(not hungry at all) 0---1---2---3---4---5---6---7---8---9---10 (so hungry you get cramps)7

Dieting HistoryWhen did your weight problem begin?Have you ever tried to control your weight?YesNoIf yes, age at first attempt: yearsYour height at that time: Your weight at that time:Why did you go on the diet?Which diets have you tried:WeightFood PyramidWatchersNutri/SystemDiabetic dietJenny CraigLiquid DietLA Weight LossRichardSimmonsSlimfastMetabolifeAtkinsHCG DietThe ZoneSouth BeachLow Carb dietSugar BustersdietBeverly Hills dietOptifastBody For LifeScarsdale DietHollywood 48 hourdietCelebrity dietThe Grapefruit dietFit For LifeMedifastMayo Clinic dietPritkin dietRaw dietBlood Test dietNegative CaloriedietCider Vinegar dietCabbage soup dietMediterranean dietSubway dietFastingCaveman dietLow Caloriehow many calories a dayOther diets:What has been your most successful diet?Why do you suppose this was the case?Have you ever seen a nutritionist? yes noWhat were their recommendations?Were their recommendations helpful?Have you ever taken medications for weight loss (either over the counter or prescription)?If so, what have you taken?8

9

(not hungry at all) 0---1---2---3---4---5---6---7---8---9---10 (so hungry you get cramps) 8 Dieting History . Atkins Mayo Clinic diet Subway diet HCG Diet Pritkin diet Fasting The Zone Raw diet Caveman diet South Beach Blood Test diet Low Ca

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