Aviva Romm MD: Homepage



Women’s Intake Form

Please complete and return this comprehensive health form no later than 48 hours prior to our appointment. I realize it might take some time for you to go through, but this will give you an opportunity to think and remember about your past medical history, about your current medical concerns and reasons for seeking my help. Having all this information on paper will be very helpful when you come in, and we will review this together during your consultation.

I look forward to working with you to achieve your health goals.

General Information

|Name: | |Age: |

|Date of Birth: |Email: |

|Address: |City: |

|Phone (Home): |Fax (Cell): |

|Background: |( African |( European |( Mediterranean |( Asian |

| | |( Native American |( Ashkenazi |( Middle Eastern | |

| | |( Other |

|When, where and from whom did you last receive medical or health care? |

|Emergency Contact: |Relationship: |

|Phone (Home): |Cell: |

|Physician (Name): |(Phone): |(Fax): |

How did you hear about the practice?

|( Clinic website |( Referral from doctor |( Referral from friend/family member |

|( Social media |( Other |

Primary Pharmacy

|Name: |Phone Number: |

|Address: |City: |State: |

|Zip: |E-mail: |Fax*: |

* It is extremely important that you list the pharmacy’s fax number.

Your Health Story

Please rank your current and ongoing health concerns in order of priority

|Describe Problem Severity |

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Life Events & Life Context

Please briefly describe any major life events or crises during:

Childhood:

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Adolescence:

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Recent Years:

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Health Goals

1. When was the last time you felt really well?

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2. How are your current health issues impacting your ability to enjoy life?

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3. Did something trigger your change in health?

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4. Do you have any insights or hunches into what’s going on with your health?

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5. What do you feel needs to happen for you to get better?

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6. What, if anything, makes you feel better?

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7. What makes you feel worse?

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8. How do you really want to feel? What does health look like or mean to you?

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9. What interested you most about this practice? What are your expectations for your Health providers?

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10. What do you hope to achieve in your visit with us?

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11. What do you see as your role in your health plan?

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12. What will a successful outcome look like to you and in what timeframe?

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Your Medical History

Allergies

|Name of Medication/Supplement/Food: |Reaction: |

|1. | |

|2. | |

|3. | |

|4. | |

|5. | |

Patient’s Birth/Childhood History

|You were born: |( Term |( Premature |( Don’t know |

| |( Yes |( No |

|Were there any pregnancy or birth complications? | | |

|If yes, explain: |

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| |( Breast-fed/How long: |( Bottle-fed/Type of formula: |

|You were | | |

| |( Don’t know |

| |( Yes |( No |

|As a child, were there any foods that were avoided because they gave you | | |

|symptoms? | | |

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|If yes, what foods and what symptoms? (Example: milk—gas and diarrhea) |

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| |( Yes |( No |

|Did you eat a lot of sugar or candy as a child? | | |

Dental History

Check if you have any of the following, and provide number if applicable:

|( Silver Mercury fillings |( Gold fillings |( Root Canal |( Implants |

|( Caps/Crowns |( Tooth pain |( Bleeding gums |

|( Gingivitis |( Problems with chewing |

|( Other dental concerns (explain) |

|Have you had any mercury fillings removed? |( Yes |( No If yes, when: |

|How many fillings did you have as a kid? |

|Do you brush regularly? |( Yes |( No |

|Do you floss regularly? |( Yes |( No |

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Environmental/Detoxification History

Do any of these significantly affect you?

|( Cigarette smoke |( Perfume/colognes |( Auto exhaust fumes |

|( Other |

In your work or home environment are you regularly exposed to: (Check all that apply)

|( Mold |( Water leaks |( Renovations |( Chemicals |

|( Old paint |( Stagnant/stuffy air |( Smokers |( Pesticides |

|( Electromagnetic Radiation |( Damp environments |( Carpets or rugs |

|( Cleaning chemicals |( Heavy metals (lead, mercury, etc.) |( Paints |

|( Herbicides |( Harsh chemicals (solvents, glues, gas, acids, etc) |

|( Airplane travel |( Other |

|Have you had a significant exposure to any harmful chemicals? |( Yes |( No |

|If yes: Chemical name, length of exposure, date: |

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|Do you have any pets or farm animals? |( Yes |( No |

|If yes, do they live: |( Inside |( Outside |( Both inside and outside |

Elimination History

Please fill in the chart below with information about your bowel movements:

|A. Frequency: |( More than 3x/day |( 1-3x/day |( 4-6x/week |( 2-3x/week |( 1 or fewer x/week |

|B. Consistency: |( Soft and well-formed |( Often float |( Difficult to pass |( Diarrhea |

|C. Color: |( Medium brown consistency |( Very dark or black |( Greenish color |( Blood is visible |

| |( Dark brown consistency |( Yellow, light brown |( Greasy, shiny appearance |

Your Medical History (YES = a condition you currently have, PAST = a condition in the past)

|Gastrointestinal |Yes |Past | |Musculoskeletal |Yes |Past |

|GERD (reflux) |( |( | |Osteoarthritis |( |( |

|Crohn’s disease/ulcerative colitis |( |( | |Chronic pain |( |( |

|Peptic ulcer disease |( |( | |Other: |( |( |

|Celiac disease |( |( | |Skin | | |

|Other: |( |( | |Psoriasis |( |( |

|Respiratory | | | |Acne |( |( |

|Bronchitis |( |( | |Skin cancer |( |( |

|Asthma |( |( | |Other: |( |( |

|Emphysema |( |( | |Cardiovascular | | |

|Sinusitis |( |( | |Heart attack |( |( |

|Sleep apnea |( |( | |Heart failure |( |( |

|Other: |( |( | |Hypertension (high blood pressure) |( |( |

|Urinary/Genital | | | |Stroke |( |( |

|Kidney stones |( |( | |High blood fats (cholesterol, triglycerides) |( |( |

|Gout |( |( | |Rheumatic fever |( |( |

|Interstitial cystitis |( |( | |Arrythmia (irregular heart rate) |( |( |

|Frequent yeast infections |( |( | |Murmur |( |( |

|Frequent urinary tract infections |( |( | |Mitral valve prolapse |( |( |

|Sexual dysfunction |( |( | |Other: |( |( |

|Sexually transmitted diseases |( |( | |Neurologic/Emotional | | |

|Endocrine/Metabolic | | | |ADD/ADHD |( |( |

|Diabetes |( |( | |Headaches |( |( |

|Hypothyroidism (low thyroid) |( |( | |Migraines |( |( |

|Hyperthyroidism (overactive thyroid) |( |( | |Depression |( |( |

|Polycystic Ovarian Syndrome |( |( | |Anxiety |( |( |

|Infertility |( |( | |Autism |( |( |

|Metabolic syndrome/insulin resistance |( |( | |Multiple sclerosis |( |( |

|Eating disorder |( |( | |Parkinson’s disease |( |( |

|Hypoglycemia |( |( | |Dementia |( |( |

|Other: |( |( | |Other: |( |( |

|Inflammatory/Immune | | | |Cancer | | |

|Chronic fatigue syndrome |( |( | |Breast |( |( |

|Food allergies |( |( | |Colon |( |( |

|Environmental allergies |( |( | |Ovarian |( |( |

|Multiple chemical sensitivities |( |( | |Skin |( |( |

|Autoimmune disease |( |( | |Other: |( |( |

|Immune deficiency |( |( | | | | |

|Mononucleosis |( |( | | | | |

|Hepatitis |( |( | | | | |

|Other: |( |( | | | | |

Please check if these symptoms occur presently or have occurred in the last 6 months

|General |Mild |

|Length of cycle: |Time between cycles: |

|Length of cycle: |( Yes |( No |Pain? |( Yes |( No |

|Have you ever had premenstrual problems (bloating, breast tenderness, irritability, etc.)? |( Yes |( No |

|If yes, please describe: |

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|Do you have other problems with your periods (heavy, irregular, spotting, skipping, etc.)? |( Yes |( No |

|If yes, please describe: |

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|Use of hormonal birth control: |( Birth control pills |( Patch |

| |( Nuva ring |( Other |

|Any problems with hormonal birth control? |( Yes |( No |

|If yes, explain: |

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|Use of other |( Yes |( No |

|contraception? | | |

| |( Condoms |( Diaphragm |( IUD |( Partner vasectomy |

|Are you in menopause? |( Yes |( No If yes, age last period: |

|Was it surgical menopause? |( Yes |( No |

|If yes, explain surgery: |

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Do you currently have symptomatic problems with menopause? (Check all that apply)

|(Hot flashes |(Mood swings |( Concentration/ |( Headaches |(Joint pain |

| | |memory problems | | |

|( Vaginal dryness |( Weight gain |( Decreased libido problems |( Loss of control of |(Palpitations |

| | | |urine | |

|Are you on hormone replacement therapy? |( Yes |( No |

|If yes, for how long and for what reason (hot flashes, osteoporosis prevention, etc.)? |

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Other Gynecological Symptoms: (Check if applicable)

|( Endometriosis |( Infertility |( Fibrocystic breasts |( Vaginal infection |( Fibroids |

|( Ovarian cysts |( Pelvic inflammatory disease |( Reproductive cancer |

|( Sexually transmitted disease (describe) |

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Gynecological Screening/Procedures: (If applicable, provide date)

|( Endometriosis |( Infertility |( Fibrocystic breasts |( Vaginal infection |( Fibroids |

|( Ovarian cysts |( Pelvic inflammatory disease |( Reproductive cancer |

|( Sexually transmitted disease (describe) |

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Gynecological Screening/Procedures: (If applicable, provide date)

|Last Pap test: |

|Last mammogram: |

|Last bone density: |

|Other tests/procedures (list type and dates) |

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Obstetric History: (Check box and provide number if applicable)

|Pregnancies: |Miscarriages: |

|Vaginal deliveries Cesarean: |

|Birth weight of largest baby: |

|Birth weight of smallest baby: |

|Did you develop any problems in or after pregnancy, for example, toxemia |( Yes |( No |

|(High blood pressure), diabetes, post-partum depression, issues with breast feeding, etc.? | | |

|If yes, please explain: |

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Please check if these symptoms occur presently or have occurred in the last 6 months

|Female Reproductive |Mild |Moderate |Severe |

|Breast cysts |( |( |( |

|Breast lumps |( |( |( |

|Breast tenderness |( |( |( |

|Ovarian cyst |( |( |( |

|Poor libido (sex drive) |( |( |( |

|Endometriosis |( |( |( |

|Fibroids |( |( |( |

|Infertility |( |( |( |

|Vaginal discharge |( |( |( |

|Vaginal odor |( |( |( |

|Vaginal itch |( |( |( |

|Vaginal pain |( |( |( |

|Premenstrual: |( |( |( |

|Bloating |( |( |( |

|Breast tenderness |( |( |( |

|Carbohydrate craving |( |( |( |

|Chocolate craving |( |( |( |

|Constipation |( |( |( |

|Decreased sleep |( |( |( |

|Diarrhea |( |( |( |

|Fatigue |( |( |( |

|Increased sleep |( |( |( |

|Irritability |( |( |( |

|Menstrual: |( |( |( |

|Cramps |( |( |( |

|Heavy periods |( |( |( |

|Irregular periods |( |( |( |

|No periods |( |( |( |

|Scanty periods |( |( |( |

|Spotting between |( |( |( |

Medications/Supplements

Current medications (include prescription and over-the-counter)

|Medication |Dosage |Start Date |Reason for Use |

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Nutritional supplements (vitamins/minerals/herbs etc.)

|Name/Brand |Dosage |Start Date |Reason for Use |

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|Have medications or supplements ever caused unusual side effects or problems? If yes,|( Yes |( No |

|describe: | | |

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|Have you used any of these regularly or for a long time: |

|NSAIDs (ADVIL, Aleve, etc.), Motrin, Aspirin? |( Yes |( No |

|Tylenol (acetaminophen)? |( Yes |( No |

|Acid-blocking drugs (Zantac, Prilosec, and Nexium etc.)? |( Yes |( No |

How many times have you taken antibiotics?

| |5 |Reason for Use |

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|Infancy/Childhood | | | |

|Teen | | | |

|Adulthood | | | |

|Have you ever taken long term antibiotics? |( Yes |( No |

|If yes, explain: |

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How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)?

| |5 |Reason for Use |

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|Infancy/Childhood | | | |

|Teen | | | |

|Adulthood | | | |

Family History

Check family members that have/had any of the following

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|Do you have problems falling asleep? |( Yes |( No |

|Do you have problems staying asleep? |( Yes |( No |

|Do you snore? |( Yes |( No |

|Do you feel rested upon? |( Yes |( No |

|Do you use sleeping aids? |( Yes |( No |

|If yes, explain: |

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Exercise

Current Exercise Program:

|Activity |Type |# of Times Per Week |Time/Duration (Mins) |

| | | | |

|Cardio/Aerobic | | | |

|Strength/Resistance | | | |

|Flexibility/Stretching | | | |

|Balance | | | |

|Sports/Leisure (e.g., golf) | | | |

|Other: | | | |

|Do you feel motivated to exercise? |( Yes |( A little |( No |

|Are there any problems that limit exercise? |( Yes |( No |

|If yes, explain: |

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|Do you feel unusually fatigued or sore after exercise? |( Yes |( No |

|If yes, explain: |

Smoking

|Do you smoke currently: |( Yes |( No |

|Packs per day: |Number of years: |

|What type? |( Cigarettes |( Smokeless |( Pipe |( Cigar |( E-cig |

|Have you attempted to quit? |( Yes |( No |

|If yes, using what methods: |

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|If you smoked previously: |Packs per day: |Number of years |

|Are you regularly exposed to second-hand smoke? |( Yes |( No |

Alcohol

|How many alcoholic beverages do you drink in a week? |

|(1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits) |

|( 1-3 |( 4-6 |( 7-10 |( >10 |( None |

|Previous alcohol intake? |( Yes ( ( Mild ( Moderate ( High) |( None |

|Have you ever had a problem with alcohol? |( Yes |( No |

|If yes, when? |

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|Explain the problem: |

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|Have you ever thought about getting help to control or stop your drinking? |( Yes |( No |

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Other Substances

|Are you currently using any recreational drugs? |( Yes |( No |

|If yes, type: |

|Have you ever used IV or inhaled recreational drugs? |( Yes |( No |

Nutrition

Do you currently follow any of the following special diets or nutritional programs? (Check all that apply)

|( Vegetarian |( Vegan |( Allergy |( Elimination |( Low Fat |( Low Carb |

|( Vegan |( Blood Type |( Low sodium |( No Dairy |

|( Kosher |( Gluten Free |( Paleo |( Macrobiotic |

|Other: Do you have sensitivities to certain foods? |( Yes |( No |

|If yes, list food and symptoms: |

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|Do you have an aversion to certain foods? |( Yes |( No |

|If yes, explain |

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|How many servings do you eat in a typical week of these foods: |

|Fruits (not juice): |Vegetables (not including white potatoes): |

|Legumes (beans, peas, etc.): |Red Meat: |Fish: |

|Dairy/Alternatives: |Nuts & Seeds: |Fats & Oils: |

|Cans of soda (regular or diet): |Sweets (candy, cookies, cake, ice cream, etc.): |

Do you drink?

|Coffee (cups per day) |( 1 |( 2-4 |( >4 |

|Tea (cups per day) |( 1 |( 2-4 |( >4 |

|Sodas—regular or diet (cans per day) |( 1 |( 2-4 |( >4 |

|Decaffeinated coffee (cups per day) |( 1 |( 2-4 |( >4 |

|Do you have adverse reactions to caffeine? |( Yes |( No |

|If yes, explain | | |

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|When you drink caffeine do you feel: |( Irritable or wired |( Aches or pains |

|Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?|( Yes |( No |

|If yes, are these symptoms associated with any particular food(s) or supplement(s)? |( Yes |( No |

|Please name the food or supplement and symptom(s). Example: Milk = gas and diarrhea: |

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|Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for|( Yes |( No |

|24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? | | |

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| |( high fat foods |

|Do you feel much worse when you eat a lot of: |( refined sugar (junk food) |

| |( high protein foods |

| |( fried foods |

| |( high carbohydrate foods |

| |( 1 or 2 alcoholic drinks |

| |( (breads, pasta, potatoes) |

| |( other |

|Do you feel much better when you eat a lot of: |( high fat foods |

| |( refined sugar (junk food) |

| |( high protein foods |

| |( fried foods |

| |( high carbohydrate foods |

| |( 1 or 2 alcoholic drinks |

| |( (breads, pasta, potatoes) |

| |( other |

|Do you adversely react to: (Check all that apply) |( Monosodium glutamate (MSG) |

| |( Artificial sweeteners |

| |( Garlic/onion |

| |( Cheese |

| |( Citrus foods |

| |( Chocolate |

| |( Alcohol |

| |( Red wine |

| |( Sulfite–containing foods (wine, dried fruit, salad bars) |

| |( Preservatives |

| |( Food colorings |

| |( Other food substances: |

|Are there any foods that you crave or binge on? (food craving may be an indicator that you may be|( Yes |( No |

|allergic to that food) | | |

|If yes, what foods? |

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|Do you eat 3 meals a day? |( Yes |( No If no, how many? |

|Does skipping a meal greatly affect you? |( Yes |( No |

|How many meals do you eat out per week? |( 0-1 |( 1-3 |( 3-5 |( >5 meals per week |

|Check the factors that apply to your current lifestyle |( Fast eater |

|and eating habits: |( Eat too much |

| |( Late-night eating |

| |( Dislike healthy foods |

| |( Travel frequently |

| |( Eat more than 50% of meals away from home |

| |( Healthy foods not readily available |

| |( Poor snack choices |

| |( Significant other or family members don’t like healthy foods |

| |( Significant other or family members have special dietary needs |

| |( Love to eat |

| |( Eat because I have to |

| |( Have negative relationship to food |

| |( Struggle with eating issues |

| |( Emotional eater (eat when sad, lonely, bored, etc.) |

| |( Eat too much under stress |

| |( Eat too little under stress |

| |( Don’t care to cook |

| |( Confused about nutrition advice |

| |( Was your childhood diet similar to your present one? |

3 Day Food Journal

Instructions for Completing the Food Journal

Please know right up front, the practitioners in this practice make absolutely no judgments about the foods our patients eat. Our goal in collecting this information is simply to be able to identify foods that might be symptom triggers for you, inform you of potential nutritional or dietary deficiencies that could be causing symptoms, and understand patterns that might be causing symptoms, cravings, or conditions. Please give us as accurate a reporting of what you’re eating at each meal, snack, and in the evening as possible.

Here are some tips for providing the most helpful possible information:

Record what you’ve eaten as soon as possible after each time you eat

Don’t change your usual eating behaviors

Describe the food or beverage consumed. e.g., milk - what kind? (whole,

2%, or nonfat); toast - (whole wheat, white, buttered); chicken - (fried, baked, breaded), etc.

Record the amount of each food consumed using standard measurements as much as possible, such as 8 ounces, 1/2 cup, 1 teaspoon, etc.

Include any added items. For example: tea with 1 teaspoon sugar, potato with 2 teaspoons butter, etc.

Please record all beverages, including water. List them in the

“Beverage” category.

Please record how you felt within 2 hours of meals, snacks, or beverages, particularly if you felt especially well, or if you noticed any symptoms.

Day 1: Food Journal

|Day Event |Food & Drink Intake |How I felt within 2 hours of eating (i.e., still |

| |(include type & amount) |hungry, tired, achy, bloated) |

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|Waking Time | | |

|Breakfast | | |

|(Time) | | |

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|Mid-AM Snack | | |

|(Time) | | |

|Lunch | | |

|(Time) | | |

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|Mid-PM Snack | | |

|(Time) | | |

|Dinner | | |

|(Time) | | |

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|PM Snack | | |

|(Time) | | |

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|Beverages | | |

|Bed Time | | |

Day 2: Nutrition Journal

|Day Event |Food & Drink Intake |How I felt within 2 hours of eating (i.e., still |

| |(include type & amount) |hungry, tired, achy, bloated) |

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|Waking Time | | |

|Breakfast | | |

|(Time) | | |

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|Mid-AM Snack | | |

|(Time) | | |

|Lunch | | |

|(Time) | | |

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|Mid-PM Snack | | |

|(Time) | | |

|Dinner | | |

|(Time) | | |

| | | |

|PM Snack | | |

|(Time) | | |

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|Beverages | | |

|Bed Time | | |

Day 3: Nutrition Journal

|Day Event |Food & Drink Intake |How I felt within 2 hours of eating (i.e., still |

| |(include type & amount) |hungry, tired, achy, bloated) |

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|Waking Time | | |

|Breakfast | | |

|(Time) | | |

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|Mid-AM Snack | | |

|(Time) | | |

|Lunch | | |

|(Time) | | |

| | | |

|Mid-PM Snack | | |

|(Time) | | |

|Dinner | | |

|(Time) | | |

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|PM Snack | | |

|(Time) | | |

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|Beverages | | |

|Bed Time | | |

Stress

|Do you feel you have an excessive amount of stress in your life? |( Yes |( No |

|Do you feel you can easily handle the stress in your life? |( Yes |( No |

|How much stress do each of the following cause |( Work |

|on a daily basis (Rate on scale of 1-10, 10 being highest) | |

| |( Family |

| |( Social |

| |( Finances |

| |( Health |

| |( Other |

|Do you use relaxation techniques? |( Yes |( No If yes, how often? |

|Which techniques do you use? |( Meditation |

|(Check all that apply) | |

| |( Breathing |

| |( Tai Chi |

| |( Yoga |

| |( Prayer |

| |( Other |

|Have you ever sought counseling? |( Yes |( No |

|Are you currently in therapy? |( Yes |( No |

|If yes, describe: |

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|Have you ever been abused, a victim of crime, or experienced a significant trauma? |( Yes |( No |

|What are your hobbies or leisure activities? |

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Relationships

|Marital status: |( Single |( Married |( Divorced |( Gay/Lesbian |

| |( Long term Partner |( Widow/er |

|With whom do you live? (Include children, parents, relatives, friends, pets) |

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|Current occupation: |

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|Previous occupations: |

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|Do you use relaxation techniques? |( Yes |( No (Check all that apply) |

| |( Spouse/Partner |

| |( Family |

| |( Friends |

| |( Religious/Spiritual |

| |( Pets |

| |( Other |

|Do you have a religious or spiritual practice? |( Yes |( No |

|If yes, what kind? |

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How well have things been going for you? (Mark on scale of 1–10, or N/A if not applicable)

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2. What external barriers or competing demands do you feel could get in the way of achieving your (health) goals?

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3. What patterns (skipping meals, etc.) or hidden beliefs (i.e. “there’s not enough time”, “I can never succeed at losing weight,” “I don’t deserve to take time for myself”, my mother was overweight so I will be too, or I’m not good enough to be successful….) might get in the way of you achieving your goals?

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4. What 3 steps can you take to overcome these, so these are not excuses or obstacles to your success?

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5. Rate how willing you are, on a scale of 5 (very willing) to 1 (not willing), to:

|Modify your diet | ( 5 |( 4 |( 3 |( 2 |( 1 |

|Take nutritional supplements each day | ( 5 |( 4 |( 3 |( 2 |( 1 |

|Keep a food journal periodically | ( 5 |( 4 |( 3 |( 2 |( 1 |

|Adjust your lifestyle (e.g., work demands, sleep habits) relaxation | ( 5 |( 4 |( 3 |( 2 |( 1 |

|technique Practice a relaxation technique) | | | | | |

|Practice a relaxation technique | ( 5 |( 4 |( 3 |( 2 |( 1 |

|Engage in regular exercise | ( 5 |( 4 |( 3 |( 2 |( 1 |

6. Rate on a scale of 5 (very supportive) to 1 (not supportive): how supportive do you think the people in your household will be to your implementing the changes you want to make?

|( 1 | ( 2 | ( 3 | ( 4 | ( 5 |

Thank you for sharing all of this personal and important information with me.

Everything you share is completely confidential.

I look forward to helping you reach your health and personal goals!

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© AVIVA ROMM, MD

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