PATIENT NAME ________________________________________________ REG# _____________________ Please CIRCLE the appropriate response next to each question below: Yes (Y), No (N), Don’t Know (?) Do you have or have you had any of the following: Explain: _______________________________Explain: _______________________________ 2. Heart or circulation problems? Explain: _________________
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Microsoft word - 4165aa27-35ea-201b71.docCholesterol Eating Analysis and Assessment Tool
Please help us learn a little about you. Please answer as completely as you can, and print
your name and the date on each sheet. Thank you.
Name (Please Print) _____________________________________________________________
E-Mail Address ________________________________________________________________
1. Please write why you are here today.
2. What specific question(s) do you want to have answered today?
3. What are the MAIN REASONS you want to reduce cholesterol? (RANK the choices below by
number:(1 is MOST IMPORTANT and 6 is LEAST IMPORTANT)
To set a good example for my family_____ To help control current health problems_____
4. What do you think is a reasonable LDL (lousy) cholesterol? _______mg/dl
5. What do you think is a reasonable HDL (healthy) cholesterol? _______mg/dl
6. Have you ever taken Statins (Lipitor, Crestor, Zocor, Mevacor, Baycol) or other cholesterol lowering
No Which Ones? _____________________________________________________ 7. How long have you had high cholesterol?___________________________________________
8. Which foods have you tried to lower cholesterol?_____________________________________
9. Compared to any past attempts, how motivated are you to lower cholesterol?
(CIRCLE ONLY ONE)
Much less motivated
10. Is there someone in your life who will be supportive of your efforts to lower your LDL/raise your
HDL? ___Yes ___No
11. If Yes, who? What is his/her relationship to you? _______________________________________
copyright, John La Puma, MD, FACP and the Santa Barbara Institute for Medical Nutrition and Healthy Weight Santa Barbara, 2004-5. Do not Cite, quote or reproduce without permission. www.drjohnlapuma.com 12. In the last 10 years, have you used Drugs or Supplements to lower your LDL/raise your HDL? If
so, which, and for how long? (CIRCLE EACH YOU USED)(LIST ALL)
Over the Counter Drugs_________________________________________How long?__________ Prescription Drugs _____________________________________________How long?_________ 13. Which, if any, of the following are true of your eating habits? (CIRCLE the TRUE statements, if
I often eat when I am lonely or bored.
I often eat for pleasure, using food as a reward. I often eat to help me deal with the stresses of home. I often eat to help me deal with the stresses of work. I am more likely to overeat when I am out with friends or in social situations. I am more likely to overeat when I am drinking alcohol.
14. Who usually shops for and prepares the food in your home? (CIRCLE ONLY ONE)
I usually shop for and prepare the food. I usually shop for the food, but someone else usually prepares it. Someone else usually shops for the food, but I usually prepare it. Someone else usually shops for and prepares the food. I generally do not eat at home.
15. On average how many breakfasts do you skip in a week?
_____BREAKFASTS SKIPPED PER WEEK
16. On average, how many lunches do you skip in a week?
_____LUNCHES SKIPPED PER WEEK
17. How many times do you eat during the day, including snacks? _____TIMES YOU EAT DAILY
18. How many times weekly do you eat out, including snacks? ____TIMES YOU EAT OUT
19. When you go out to eat, what two dishes do you order MOST OFTEN?
20. How many minutes do you spend cooking your main meal daily?
______MINUTES COOKING YOUR MAIN MEAL DAILY
21. Which are the three foods you eat MOST OFTEN as snacks?
22. About how many hours per week do you watch television and eat at the same time?
______TV HOURS WATCHED PER WEEK WHILE EATING
copyright, John La Puma, MD, FACP and the Santa Barbara Institute for Medical Nutrition and Healthy Weight Santa Barbara, 2004-5. Do not Cite, quote or reproduce without permission. www.drjohnlapuma.com 23. Have you had or do you have (CIRCLE ALL THAT APPLY)
High Blood Pressure Operations, any kind Stroke Diabetes High Cholesterol Back or Knee Injury Thyroid Problems
23. Do any diseases run in your family? If so, which?_______________________________________
24. Do you have kids? Names? Ages?_________________________________________________
25. Do you use any of the following? (CIRCLE ALL THAT APPLY)
Coffee/Tea: How many cups per day?___?___ Energy Drinks/Soda: How many per day ?____/___
Cigarettes: ____# per day ____# of years
26. Do you presently have a regular exercise program? ____yes ____no
if yes, please describe:_________________________________________________________________
27. Have you ever had an exercise-related injury? ____yes ____no
if yes, please describe:________________________________________________________________
28. Have you ever had an exercise stress test? ____yes ____no If yes, date/location: ______________
29. PLEASE CIRCLE the number of any statement that applies to you.
1. I eat out 10 or more times in a week 2. I consume 14 or more alcoholic drinks in a week 3. I seldom eat more than 2 servings (combined) of fruit and vegetables daily. 4. I drink more than 20 ounces of soft drink/pop daily 5. I seldom exercise 60 minutes or more in a week. 6. I consume refined sugar/simple carbohydrates several times daily 7. I often eat between meals 8. I eat foods such as burgers, hot dogs, commercial pizza, fried chicken, fries, chips almost daily. 9. I have a problem with stress eating or compulsive eating. 30. How did you first hear about Dr. La Puma? (Please SPECIFY)
Class/Conference(WHICH?)____________TV Show (WHICH?)__________________________
Internet Site(WHICH?)________________ Referral(WHO?)____________________________
copyright, John La Puma, MD, FACP and the Santa Barbara Institute for Medical Nutrition and Healthy Weight Santa Barbara, 2004-5. Do not Cite, quote or reproduce without permission. www.drjohnlapuma.com
Unit type Application Article name Autor/Organisation Published For electro-bioremedation, technology used for the Lei Shi, Hauke Harms and Lukas Y. Wick / UFZ Helmholz- Environ, Sci. Technol., treatment of contaminated Stimulates the Relese of Centre for Environmental Research, Department of Environmental Microbiology, Leipzig, GermanyS J Bidarra, C C Barrias, M A Barbosa, R S