How does a
lifestyle analyses work?
Complete
this lifestyle analyses form, photocopy it and mail it
to me.
Email: medicalnutritiontherapy@gmail.com
and I will give you the address where to mail your check or money order.
Feel
free to tape record our sessions,
so you can listen to them over and over.
After I review and analyze the information, below, I will devise a list of recommendations and share them with you
at our first consultation. After you review my
suggestions, be certain you understand what I am
recommending and how you will implement it.
Avoid being too shy to say, "I DON'T
UNDERSTAND". We will email or phone each other until you
do understand completely, what to do next. If you would like to continue working with
me, you can book follow-up sessions, as
you please, or invest in a package of counseling sessions.
If you
are on a strict budget, workshops are the way to go. Invite 10 or more of
your friends and associates. If you live too far to visit, we can do
the class via web cam.
The best thing about building a small group is that you are creating a network of
like-minded friends and associates to assist you in staying on the plan,
year after year.
LIFESTYLE ANALYSES:
If you leave certain areas blank,
that is O.K. Just do your best.
Copyright © 2008 Helene Berk, M.Ed., R.D. healthypeople.com
MEDICAL
NUTRITION THERAPY
LIFESTYLE ANALYSIS
Your Name:
__________________________________________________________
Address:_____________________________________________________________
Work Phone, ext.______________________________________________________
FAX:________________________________________________________________
Home Phone:_________________________________________________________
Email:_______________________________________________________________
INSURANCE INFORMATION
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
If you want your insurance company to help pay for the session,
include any information you feel would be necessary to make that happen, e.g., name and phone number of insurance company, member number, etc.
You will still need to pay up front,
but I will help you get reimbursed in any way that I can.
Why do you need Medical Nutrition
Therapy?
Describe your goals in detail:
What do you feel is missing from your life?
What do you do to relax? How often?
Do you sleep well at night? How many hours do you
get? When do you go to sleep? What time do you wake up?
Do you eat certain foods or drink certain beverages
when you feel emotionally out of balance,
e.g., anxious, overwhelmed,
depressed or whatever feeling you are numbing out?
What is your beverage of choice? What are your
favorite foods?
What foods do you "hate"?
Are you struggling with any addictions?
Do you smoke cigarettes? How often? Do you want to
stop, eventually?
Do you get sleepy in the afternoon?
...or do you get tired at another time of day?
On a scale of 1 to 10
(1 = not true, 10 = true):
"I feel connected to my family, my friends and
my world."
"I feel peaceful most of the time."
"I am always filled with tension."
"I am a loner."
"I always have people around me. I hate being
alone".
"I have low self esteem: I don't like my
Self"
"I take time to explore my Self, and cultivate
achievable, doable goals."
"I am obsessed with dieting and my body
weight."
"I struggle with perfectionism -- I am never
happy with my Self."
"I feel loved and cared for. I have a healthy
relationship with my Self."
"My body is in good health. I eat
nutrient-dense foods most of the time."
"I study nutrition in my spare time"
"I take the time to appreciate my food."
"I eat late at night".
"I wolf down my food."
"I eat only when I am physically hungry, not
mentally hungry".
Do you have a history
of...?
any medical condition not listed here:
(Circle those that apply and list recent lab values)
cancer (specify type):
cardiovascular disease
(heart disease, heart attack, clogged arteries, high LDLs, low HDL's):
depression:
syndrome X (metabolic syndrome or
pre-diabetes)
diabetes / pre-diabetes:
eating disorders:
high blood pressure:
high triglycerides:
immune deficiency
(a weak immune system):
pain / physical injuries:
Are you on any medications?
Are you taking any supplements?
...any psychological "baggage" you'd like
to share,
that you feel affects your mental-emotional-spiritual health?
Do you consider your Self a chronic dieter?
Which diets have you embarked upon?
Explain and list any medications you are
taking.
How are they working for you? Do you notice any side effects?
Any vitamins, minerals, herbal remedies, homeopathic
remedies, etc. ???
Please
complete as much of the following lab data as you can.
You can fill in the
blanks, later.
Age:________________________________
Gender:_____________________________
Height (inches):______________________
Weight:______________________________
% + lbs. of Body Fat:___________________
% + lbs. of Lean Mass__________________
Phase Angle (list dates)________________
Body Capacitance list dates):__________
Intra-Cellular Hydration: ______________
Over All Hydration:___________________
BMR - Basal Metabolic Rate:___________
Activity Level (circle one): light, medium,
heavy
What type of work do you do?
Is it physically demanding or a desk job?
How much sleep do you get each night?
LAB VALUES
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
HDL cholesterol:___________________________________________________________________
[HDL = High Density Lipoproteins -- the good stuff]
LDL cholesterol:____________________________________________________________________
[LDL = Low Density Lipoproteins -- the bad stuff]
Total cholesterol:____________________________________________________________________
Triglycerides:________________________________________________________________________
Hemoglobin
A1C:___________________________________________________________________
Homo-cystiene (An amino acid):__________________________________________________________
Albumin:_____________________________________________________________________________
Glucose:_____________________________________________________________________________
3 Most Recent Blood Pressures:________________________________________________________
_____________________________________________________________________________________
Blood Pressure Response to Exercise:___________________________________________________
_____________________________________________________________________________________
Phase Angle: ______________________________________________________________________
_____________________________________________________________________________________
DIET HISTORY
Please submit a 3 day
food diary with your lifestyle analyses
what do you eat
throughout the day? Record the time, quantity, foods and beverages. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Have you dieted in the past?
What type of diet?
Do you still follow strict diets?
Do you prefer structured food plans
or would you rather wing it from meal to meal.
Do you prefer three larger meals
or do you prefer to nibble throughout the day
Do you eat in response to stress, boredom,
anxiety, frustration, anger, etc.
Do you wait until you are hungry to eat?
Do you eat to the point of stuffing yourself
regularly? sometimes? never?
Do you eat foods you consider to be
nutrient-dense
most of the time? sometimes? never?
Do you drink coffee? Is it organic?
How much do you drink, and when?
Do you drink tea? What type of teas?
How often?
Do you use sweeteners? What kind?
How Often?
Do you drink fruit juice? What kind?
How Often?
Do you drink diet soda? How much? When?
Do you drink wine, beer, liquor? When and How often?
LIST AT LEAST 20 OF
YOUR FAVORITE FOODS
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
EXERCISE & MEDITATION
HABITS
~~~~~~~~~~~~~~~~~~~~~~~~~~
Do you practice stretching exercises?
Do you strengthen your muscles with resistance
exercises?
What exercises do you do? How often?
Do you get at least 30 minutes of cardiovascular
exercise every day?
What are your top five favorite cardiovascular activities:
- walking,
- running
- dancing
- biking
- hiking
- swimming
- exercise classes
- Tai Chi
- Yoga
- Tennis
- Golf (no carts)
- Other
Do you meditate? How long? How often?
Are you happy?
If not, what do you believe it would take to make
you happy?
Do you feel joy on a daily basis...or at
least frequently?
