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Health Stat Health Stat Document Transcript

  • First Name Last Name Gender Birthdate Truck Number MALE teter FEMALE Address 1 Address 2 State City Zip Code -- Work Phone Home Phone E-Mail Job Description Location Company Status What is your percent Body Fat?...... 12.1 What is your current Weight?............................................................... Pounds What is your current Height?............................................................... 6 Feet 1 inches What is your current Waist Measure?..................................................... inches What is your current Hip Measure?......................................................... inches What is your current Neck Measure?...................................................... inches What is your Heart Rate & Blood Pressure? What are your most recent Cholesterol Numbers? Blood Pressure……………. / Total Cholesterol……… Heart Rate…………………… Triglycerides…………… HDL……………………… What are your Blood Sugar Measures? LDL……………………… Glucose………………………………. HbA1c…………………………………
  • Do you Smoke? YES NO USED TO Mark the choice that is most like your plans about smoking cigarettes: If 'Yes', How Much? per day I Do not Smoke If you 'Used To' Smoke, When Did You Quit I do not plan to quit smoking within the next 6 months ago I am thinking about quitting smoking within the next 6 months Do You Smoke or Use… I am making plans to quit smoking within the next 30 days s Pipes s Cigars s Smokeless Tobacco I am currently trying to quit smoking Do you work or live with anyone who regularly smokes around you? YES NO Do you feel that you fully understand the health risks of tobacco use? YES NO In general, how satisfied are you with the balance between your personal life and your professional life? Completely Satisfied Mostly Satisfied Partly Satisfied Not Satisfied How often do you brush your teeth? q Never or Rarely q Once per Day q 2 or More Times per Day Do you floss daily? YES NO Considering your age, How would you describe your overall health? Excellent Very Good Good Fair Poor When you lift a heavy object do you bend your knees and keep your back straight? YES NO When in the sun, do you use sunscreen or wear adequate clothing? YES NO In the past 12-months, how many times have you: 0 1-2 3-5 6 or more Visited a Physician's Office or Clinic Gone to an Emergency Room Stayed Overnight in a Hospital In the next 3-months, are you planning to make any changes to keep yourself healthy or improve your health? I'm Already Want to start working Yes No Not Needed Doing This on this today Increase Physical Activity Choose only 1 Lose Weight Choose only 1 Reduce Alcohol Use Choose only 1 Quit or Cut Down Smoking Choose only 1 Reduce Fat and/or Cholesterol Intake Choose only 1 Lower Blood Pressure Choose only 1 Lower Cholesterol Level Choose only 1 Cope Better With Stress Choose only 1
  • How many times per day do you eat a meal? How often do you eat Hight Fat Foods? How often do you Snack? Once Per Day Twice Per Day Several Times Per Day What types of Snacks? Fruits, Veggies, Grains High Fat (Chips) High Sugar (Candy) Drinks Number per Day Would you be interested in completeing a 5-day s Regular Soda nutrition log to get a better idea about your nutritional needs? s Diet Soda YES NO s Water s Energy Drinks Mark on the response which best describes your plans for eating more fruits and/or vegetables: I do not plan to eat more fruits and/or vegetables within the next 6 months I am thinking about eating more fruits and/or vegetables within the next 6 months I am making plans to begin eating more fruits and/or vegetables within the next 30 days I am currently trying to increase the amount of fruits and/or vegetables that I eat on most days Mark on the response which best describes your plans for eating fewer High-Fat Foods: I do not plan to eat fewer high-fat foods within the next 6 months I am thinking about eating fewer high-fat foods within the next 6 months I am making plans to begin eating fewer high-fat foods within the next 30 days I am currently trying to decrease the amount of high-fat foods that I eat on most days Mark on the response which best describes your plans for Drinking fewer High-Sugar Drinks: I do not plan to drink fewer high-sugar drinks within the next 6 months I am thinking about drinking fewer high-sugar drinks within the next 6 months I am making plans to begin drinking fewer high-sugar drinks within the next 30 days I am currently trying to decrease the amount of high-sugar drinks that I drink on most days Mark on the response which best describes your plans for eating more Appropriate Portion Sizes: I do not plan to eat more appropriate serving sizes within the next 6 months I am thinking about eating more appropriate serving sizes within the next 6 months I am making plans to begin eating more appropriate serving sizes within the next 30 days I am currently trying to eat appropriate serving sizes on most days Are you currently trying to lose weight? YES NO
  • How would you describe your physical activity level? How many days per week do you get 30-minutes or more of continuous physical activity? How many days per week do you do exercices specifically for your back and stomach? How many days per week do you perform stretching exercises? How often do you do strength building exercises like push ups, resistance bands, or weight lifting? Have you increased the amout of exercise you do in a typical week? Yes, In the last 6-months Yes, More than 6-months ago No Mark the Boxes next to the TWO health benefits that are most important to you. Check only TWO (2) Build Endurance Heart Health s Reduce Blood Pressure Control Diabetes Weight Loss s Reduce Injury Risk Reduce Fatigue Build Muscle s Stress Management In the next 6-months, would you participate in a program that would help improve your overall health? Yes No Not Sure How would you feel if someone were to see you exercising? Proud Embarassed Wouldn't Care Do you spend a lot of time thinking about ways to be / stay thin? Yes No Have you had fun during the past two weeks? Yes No Do you have any 'old injuries' that would make it hard for you to exercise? (check all that apply) Neck s Pain s Weakness Decreased Range of Motion Back Pain Weakness s Decreased Range of Motion Shoulder Pain Weakness Decreased Range of Motion Elbow Pain Weakness Decreased Range of Motion Wrist s Pain Weakness s Decreased Range of Motion Hip Pain Weakness Decreased Range of Motion Knee Pain Weakness Decreased Range of Motion Ankle Pain Weakness Decreased Range of Motion
  • Family History Mother Father Sister / Brother Grandparent Heart Attack Stroke High Blood Pressure High Cholesterol Diabetes Breast Cancer Prostate Cancer Colon or Rectal Cancer Obesity Depression Alcoholism Has a doctor ever told you that you Are you currently taking any of the following have any of the following medications prescribed by your doctor? conditions? Allergy Medication Allergies Anti-Anxiety Medication s Asthma Asthma Medication (Inhaler) Osteoarthritis Asthma Medication (Pills) Bone Loss / Osteoporosis Aspirin (1/day for Heart) s Breast Cancer Blood Thinners (like Coumadin) Prostate Cancer Chronic Pain Medication Colon or Rectal Cancer Depression Medication Lung Cancer Insulin (Injected) s Melanoma Skin Cancer s Any Other Cancers Oral Diabetes Medication Chronic Back Problems s Heart Disease Medication Depression High Blood Pressure Medication Type I Diabetes High Cholesterol Medication Type II Diabetes s High-Triglycerides Medication Irritable Bowel Syndrome / Crohn's Disease Medication for Lung Disease (COPD/Emphysema/Chronic Bronchitis) Stomach Ulcers Muscle Relaxants Heart Disease / Angina / Heart Surgery Sleep Medication High Blood Pressure Are you currently taking any of these over the High Cholesterol counter medications? High Triglycerides Antihistamines Lupus Decongestants (for example: Sudafed) Multiple Sclerosis Herbal Medications / Supplements Rheumatoid Arthritis Sleep Medication Kidney Disease Non-Prescription Pain Medication (Aspirin/Advil/Alieve) Migrane Headaches Epilepsy Sleep Disorder Stroke
  • Certain Medical and Self-Care Exams should be done on a regular schedule. When was your last: MEN Physical Exam You should thouroughly Dental Exam check your testicles Vision Exam monthly for lump, pain, or other changes. Cholesterol Check Flu Shot Do You Do This? Tetanus Booster YES NO Hepatitis B Vaccine MEN Prostate Specific Antigen WOMEN WOMEN You should thouroughly Clinical Breast Exam check your breasts Mamogram monthly for lump, pain, or other changes. Pap / Pelvic Exam Do You Do This? If You are Over 50 or have a Family History of Cancer: YES NO When was your last: MEN & WOMEN Digital Rectal Exam You should thouroughly Sigmoidoscopy check your skin monthly Colon X-Ray for lump, pain, or other changes. Colonoscopy Do You Do This? WOMEN: YES NO Have you entered manopause? YES NO How often do you feel fatgued or tired after your sleep? Do you Snore? Yes No If yes, Your Snoring is: Has anyone ever told you that you quit breathing during your sleep? Yes No How do you feel that you are currently coping with life in general? How often does your own anger or irritation upset your work or personal life? Do you feel that you are able to speak openly about your feelings when you are angry or worried? Yes No Digitally signed by erik teter erik teter DN: cn=erik teter, o=linkamerica, ou=linkwell, email=eteter@gmail.com, c=US Date: 2009.09.17 09:06:45 -05'00'