Lifestyle IQ 1.2.1
1 NON-CONTROLLABLE
Non-controllable factors are things over which you have little or no control such as your age and heredity.
 
 
1.1 Age & Gender
Your age and gender, at every stage of your life, has an impact on the overall condition of your body.
 
1) Please select your gender.
        Male
      Female
 
2) How old are you?
        10 to 19 years
      20 to 30 years
      31 to 40 years
      41 to 50 years
      51 to 60 years
      61 years or older
 
 
1.2 Genetics
This category is based upon your family history. Genetic scoring is based on family members that were diagnosed with or died from specified diseases before and after age 55 years.
 
1) Please select diseases that your immediate family members have suffered from after the age of 55.
        Alzheimers Disease
      Arthritis
      Cancer (Other than skin cancer)
      Diabetes
      GI Disease
      Heart Disease / Stroke
      Liver or Kidney Disease
      Osteoporosis
      Prostate Disease
 
2) Please select diseases that your immediate family members have suffered from before the age of 55.
        Alzheimer's Disease
      Arthritis
      Cancer (Other than skin cancer)
      Diabetes
      GI Disease
      Heart Disease / Stroke
      Liver or Kidney Disease
      Osteoporosis
      Prostate Disease
 
 
2 CONTROLLABLE
Controllable factors are things in your daily life that can be modified or changed. The goal would be to point out habits or practices that are currently contributing to a less than optimal health condition. This will enable your pharmacist/counselor to assist you in determining which of these could be changed in order to potentially enhance your health and longevity.
 
 
2.1 Diet
Diet scoring is based on current eating habits. Please be as thorough and as honest with yourself as you can as this section is used to help your pharmacist/counselor get a complete picture of your current daily food intake.
 
1) How long after first waking do you wait to eat?
        Less than one hour
      1 to 1.5 hours
      1.5 to 2 hours
      2 to 3 hours
      More than 3 hours
 
2) What time do you normally eat breakfast?
        Before 7AM
      Between 7AM-8AM
      Between 8AM-9AM
      After 9AM
      I do not normally eat breakfast
 
3) Do you eat a morning snack between breakfast and lunch?
        Yes
      No
 
4) What time do you normally eat lunch?
        Between 11AM and noon
      Between noon and 1PM
      After 1PM
      I do not normally eat lunch
 
5) Do you eat an afternoon snack?
        Yes
      No
 
6) What time do you normally eat dinner/supper?
        Before 6PM
      Between 6PM and 7PM
      Between 7PM and 8PM
      After 8PM
      I do not normally eat dinner/supper
 
7) Do you routinely eat a snack between dinner/supper and bedtime?
        Yes
      No
 
8) On average, what type and how many servings of fat, dressings and spreads you consume per day? (May have more than one answer)
        Use low-fat selections sparingly (less than 3 per day).
      Use low-fat selections frequently (more than 3 per day).
      Use both low-fat and high-fat about the same sparingly (less than 3 per day).
      Use high-fat selections sparingly (less than 3 per day).
      Use high fat selections frequently (more than 3 per day).
 
9) On the average, how much water do you consume per day?
        At least 64 oz per day (8 glasses).
      Between 32 and 64 oz per day.
      Less than 32 oz per day.
      Seldom consume plain water.
 
10) On the average, how many meals do you consume per day?
        3 meals with healthy snacks.
      3 meals without snacks.
      I only eat 2 meals per day
      I only eat one meal per day
      No regular eating pattern.
 
11) On the average, how many servings of dairy products do you consume per day?
        At least 2 servings each day.
      Less than 2 servings each day.
      Rarely consume dairy products.
 
12) On the average, how many servings of fruits do you consume per day?
        At least 2-4 servings each day.
      Less than 2 servings each day.
      Rarely consume fruits.
 
13) On the average, how many servings of vegetables do you consume per day?
        At least 3-5 servings each day.
      Less than 3 servings each day.
      Rarely consume vegetables.
 
14) On the average, how many times per day do you eat convenience foods or forms of fast food?
        Never.
      Less than once daily.
      Average once daily.
      More than once daily.
 
15) Which best describes your daily grain consumption? (May have more than one answer)
        Whole grains at least 6 servings per day.
      Whole grains less than 6 servings each day.
      Refined grains such as white bread, rolls, processed flour at least 6 servings each day.
      Refined grains such as white bread, rolls, processed flour less than 6 servings each day.
      Rarely consume grains.
 
16) Please indicate the type of dairy products you consume.
        Non-fat selections only.
      Both low-fat and non-fat about the same.
      Low-fat only.
      Ususally high-fat selections.
      Do not consume dairy products.
 
17) Please indicate the type of meat you normally consume. (May have more than one answer)
        Do not consume meat or meat products.
      Consume less than 6 oz of lower fat meats (fish, chicken) per day
      Consume more than 6 oz of lower fat meats (fish, chicken) per day
      Consume less than 6 oz of higher fat meats (beef, pork) per day
      Consume more than 6 oz of higher fat meats (beef, pork) per day
 
 
2.2 Exercise
This section is used to give your pharmacist/counselor a picture of your current exercise schedule and intensity.
 
1) On average, how many days per week do you exercise?
        I do not exercise.
      1 to 2 days per week
      3 to 4 days per week
      5 days or more per week
 
2) If you do not exercise on a regular basis, what factors influence that decision? (Check all that apply)
        Cannot seem to find the time.
      Cannot find an exercise that I like.
      I'm not physically able to do any exercise.
      I'm just not motivated to exercise.
      I can't afford to go to a gym or exercise class.
      Child care is an issue for me.
      I have no one to hold me accountable for exercising (spouse, partner, friend etc.)
      I don't know how to exercise (i.e. proper technique, how long, how many reps, how much to push myself etc.)
      Other Reasons _____________________________________________________
 
3) If you are currently exercising, what type of exercise(s) do you participate in? (Check all that apply)
        Walking, leisure
      Walking, cardio
      Jogging
      Running
      Weight lifting or resistance training
      Aerobic class (Tae bo, step aerobics, jazzercise etc.)
      Soft martial arts (tai chi, yoga etc.)
      Extreme martial arts (Karate, tae kwon do, judo etc.)
      Swimming
      Water aerobics
      Biking
      Climbing
      Pilates
      Cross country skiing
      Other __________________________________________________________
 
 
2.3 Lifestyle
This section has been created to assist your pharmacist/counselor in assessing your overall health risk. These factors include questions on how well you maintain your body, preventative health care and lifestyle habits that may be risky for your overall well-being.
 
1) Do you know your current Body Fat %? (If you do not know your Body Fat % your health care professional can provide this number for you after testing)
        below normal
      within normal range
      1 to 4 percent higher than normal
      5 to 9 percent higher than normal
      10 to 14 percent higher than normal
      15 to 19 percent higher than normal
      at least 20 percent higher than normal
      I don't know it
 
2) Do you know your current Body Mass Index BMI? (If you do not know your BMI your health care professional can provide this number for you after testing)
        Less than 19.9
      20-24.9
      25-29.9
      30-34.9
      Greater than 35
 
3) As a child, did you drink milk or eat cheese at least once daily?
        Yes
      No
 
4) Do you currently take a daily aspirin?
        Yes
      No
 
5) Do you currently take a natural oil supplement such as Omega-3 or Flax?
        Yes
      No
 
6) Do you currently take Vitamin D and/or calcium supplements?
        Yes
      No
 
7) Do you exercise your mind regularly with puzzles, riddles, word and games?
        Yes
      No
 
8) Do you have bone density screenings?
        Yes
      No
 
9) Do you live an active, satisfying spiritual and/or family life?
        Yes
      No
 
10) Do you see your physician for regular health check-ups and/or screenings?
        Yes
      No
 
11) Do you wear sunblock?
        Yes
      No
 
12) Does your job require repetitive movement?
        Yes
      No
 
13) Have you ever experienced any significant head injuries?
        Yes
      No
 
14) Have you ever experienced any significant joint injuries?
        Yes
      No
 
15) How often do you consume caffeine in your diet, including coffee, tea and/or soda?
        Never.
      Occassionally, but not every day.
      1-3 servings per day
      3-5 servings per day
      more than 5 servings per day
 
16) If you are over the age 40, do you have annual colon/rectal screenings?
        Yes
      No
 
17) In general, would you describe yourself as someone with high stress?
        Yes
      No
 
18) In your lifetime, have you ever experienced extended exposure to any carcinogenic (cancer causing) chemicals or substances?
        Yes
      No
 
19) Indicate which of the following best represents your current smoking status.
        I have never smoked.
      I quit less than 5 years ago.
      I quit more than 5 years ago.
      I smoke less than 1 pack per day
      I smoke more than 1 pack per day
 
20) On average, how many alcoholic drinks do you have per week?
        I don't drink.
      Less than 1 drink per week.
      1 to 2 drinks per week
      3 to 5 drinks per week
      6 or more drinks per week
 
21) Do you regularly take a quality multi-vitamin formula?
        Yes
      No
 
 
3 SEMI-CONTROLLABLE
This category has questions concerning subjects over which you have limited control. These include conditions for which you may have already been diagnosed. These risk factors may be positively affected by lifestyle modification but in some cases the impact may be limited.
 
 
3.1 Diagnosis
If a patient has been diagnosed, they should score in the Urgent risk level.
 
1) Have you ever been diagnosed with any of the following disease(s)?
        Alzheimer's Disease
      Arthritis
      Cancer (Other than skin cancer)
      Diabetes
      GI Disease
      Heart Disease / Stroke
      Liver or Kidney Disease
      Osteoporosis
      Prostate Disease
 
 
3.2 Symptoms
If a patient is showing symptoms, they should score in the High risk level.
 
1) Have you ever experienced any of the following symptoms?
        Increased memory loss such as misplacing things or repeating yourself.
      Numbness on one side.
      Light colored stools.
      Difficulty with familiar tasks and or language.
      Sudden confusion or disorientation.
      Bloating or distention.
      Disorientation to time and place.
      Sudden dizziness.
      Osteopenia.
      Loss of initiative or motivation.
      Impaired or blurred vision.
      Joint aches, pains and/or stiffness.
      High blood sugar levels.
      Hip fracture.
      Pancreatic disorder or disease.
      Loss of height.
      Gallbladder disease.
      Spinal deformities.
      Frequent urination.
      Back pain.
      Persistently swollen glands.
      Stooped posture.
      Indigestion.
      Increased fatigue.
      Increased urination at night.
      Irritability.
      Difficulty starting or stopping flow of urine.
      Breast lump or thickness.
      Divurticulitis / Diverticulosis, IBS and/or IBD
      Weakened flow of urine.
      Testicle lump or thickness.
      Stomach ulcer.
      Painful or burning during urination.
      Breast discharge.
      Constipation, diarrhea and/or both.
      Difficulty with erection.
      Unususal vaginal bleeding.
      Heartburn.
      Painful ejaculation.
      Change in mole or freckle.
      Hemorrhoids.
      Blood in semen.
      Persistent cough or sore throat.
      Arrhythmia or heart murmer.
      Pain or stiffness in lower back, hips or thighs.
      Unexplained weight loss.
      Pain in chest or upper body.
      Shortness of breath.
      Anemia
      Sudden dizziness or passing out.
      Unusual headaches.
      Neausea or vomitting.
      Difficulty healing sores
      Hepatitis.
      Hypertension or High Blood Pressure
      Primary biliary Cirrhosis
      High cholesterol.
      Diabetes
      Jaundice.
      Atrial Fibrillation
      Decreased appetite.
 
 
4 READINESS
This section addresses your current state of mind about lifestyle modification. Your honest answers will assist your pharmacist/counselor in determining your willingness to accept changes in your lifestyle. With this information your pharmacist/counselor can help you decide whether the Take Charge Professional Weight Loss/Healthy Lifestyle Strategies Program can be of benefit to you.
 
1) What made you decide to do something about your weight now? (Check all that apply)
        Concerned about my health
      A spouse/friend/family member asked me to
      My physician told me to lose weight
      Concerned about the way I look
      I had a recent health episode that scared me
      Other __________________________________________
 
2) How did you hear about the Take Charge program?
        Friend
      Current pharmacy customer
      Advertising
      Physician recommended
      Other __________________________________________
 
3) What was the last year of school that you completed?
        Below 12th grade
      Finished high school
      Some college
      Graduated college
      Advanced college degree (Masters, Doctorate)
 
4) Does your job require you to work a shift other than daytime?
        No, first shift or daytime only.
      Yes, second shift (i.e. 3PM - 11PM)
      Yes, third shift (i.e. 11PM - 7AM)
      Yes, I work swing shifts (i.e. different shifts on varying schedule)
 
5) At what age did your weight become a problem?
        Always have had a problem controlling my weight
      Before age 30
      Between 30-40
      Between 40-50
      After age 50
 
6) How would YOU describe your present weight?
        About average for my age
      Slightly overweight
      Moderately overweight
      Very overweight
 
7) Do you agree that you must do some things differently in order to achieve the results you desire?
        Yes, I am willing to change
      No, I feel I can do it without change
      Maybe. I will listen but there are some things I will not change
 
8) If losing weight meant giving up some things you currently enjoy, would you attempt to change those things?
        Yes, I am ready to try.
      No, there are things I will not give up.
 
9) In order to feel and look the way you want, how much weight do YOU feel you must lose?
        15 to 20lbs
      21 to 40lbs
      41 to 60lbs
      61 to 80lbs
      81 to 100lbs
      More than 100lbs
 
10) What is YOUR level of motivation to lose weight at this time?
        Somewhat motivated but someone else is pushing me
      Motivated, but I have doubts as to whether or not I can be successful
      Very motivated, I feel excited about what lies ahead
      Extremely motivated, I will do whatever it takes and have no hesitation
 
11) Have you attempted weight loss in the past by joining a "program?" (Check all that apply)
        Yes, Weight Watchers.
      Yes, Jenny Craig.
      Yes, Nutri-System.
      Yes, other ________________________________________
      No, I have never tried an organized "system or program."
 
12) If you answered yes to question above: What did you like about that program or programs? (Check all that apply)
        Accountability
      Selection of foods
      Group setting
      Convenience
      Price
      Other __________________________________________________________
 
13) If you answered yes to question 11 above, what did you NOT like about the program? (Check all that apply)
        Lack of accountability
      Selection of foods
      Not a convenient meeting time
      Too much pressure
      Compared myself to other people
      Price
      Other __________________________________________________
 
14) If you answered yes to question 11 above, what kind of results did you achieve?
        I was not successful did not lose any weight
      5-10lbs
      11-25lbs
      26-40lbs
      41-59lbs
      More than 60lbs
 
15) How many times have you tried dieting on your own?
        Never tried it on my own
      1-5 times
      6-10 times
      Too many to count
 
16) If you tried dieting on your own, what types of diets did you attempt? (Check all that apply)
        Low carbohydrate (Atkins, South Beach etc.)
      Low fat (Ornish, Sonoma etc.)
      High protein
      No special name just tried cutting back on portions
      Other ________________________________________________________
 
17) Why do you feel you haven't been able to totally succeed in previous attempts at weight loss? (Check all that apply)
        Lack of willpower
      Didn't know what to eat
      Didn't know how much to eat
      No one to hold me accountable
      I set unreasonable goals
      No support from family or friends
      Lost weight but was not able to maintain weight loss
      Other ______________________________________________________
 
18) How do YOU feel about your appearance?
        Very satisfied
      Satisfied
      Dissatisfied
      Very dissatisfied
 
19) How would YOU describe your present health?
        Poor
      Less than average
      Average
      Good
      Excellent
 
20) Have you ever experienced an allergic reaction to products containing soy?
        Yes
      No
 
21) If you answered yes to the question above about soy, what type of reaction did you experience?
        Nausea and/or vomiting, diarrhea, stomach cramping
      Rash
      Difficulty breathing
      Other _____________________________________________
 
22) Have you ever experienced an allergic reaction to products containing milk?
        Yes
      No
 
23) If you answered yes to the question above about milk, what type of reaction did you experience? (Check all that apply)
        Nausea and/or vomiting, diarrhea, stomach cramping
      Rash
      Difficulty breathing
      Other ______________________________________
 
24) Have you ever experienced an allergic reaction to products containing wheat or gluten?
        Yes
      No
 
25) If you answered yes to the question above about wheat or gluten, what type of reaction did you experience?
        Nausea and/or vomiting, diarrhea, stomach cramping
      Rash
      Difficulty breathing
      Other ____________________________________________