|
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 ____________________________________________
|
|
|
|