Nutrition and Lifestyle Consultation

Totoe Medical Services

Nutrition and Life style Consultation
Welcome to the Totoe Medical Services! And congratulations on making the first step towards a healthier future. Your lifestyle advisor is here to help you.

To enable us to tailor our service to your specific needs, it helps us to gather some information about you and your current lifestyle. As appointment times are valuable and limited, it is helpful if you can complete provide this information via this online form before your next appointment. If you prefer to use your appointment time to gather all or some of this information, then that is absolutely fine and your Lifestyle Advisor will go through the questions with you.

The contents of the form are subject to the same strict confidentiality as discussed in your appointment, and our systems are HIPAA compliant.
Name

First NameLast Initial
Email
example@example.com
GP Surgery
What lifestyle changes are you interested in? (pick all that apply)

Healthy eating and weight managementBecoming more physically activeStopping smokingReducing alcohol consumptionImproving general wellbeing
What type of support would you like?

Information onlyOne to one supportGroup support
When would you like to start to make changes?

Already startedThis weekWithin a monthWithin six monthsDon't know
What is your ethnicity? Please tell us below:
Are you disabled?

YesNoPrefer not to say
What best describes your employment situation?

In full time paid employmentIn part time paid employmentFull time studentVolunteerFull time parentUnemployedRetiredOther
What is your height?
What is your current weight?
All information shared with the service will be treated in absolute confidence subject to the following:
Do you consent to your information being shared with your doctor if needed?

YesNo
Do you understand that information may be shared with the relevant authorities should there be reason to raise a safeguarding concern?

YesNo
The following questions relate to your current lifestyle. Please answer as fully as possible but do not worry if you are unsure of any of the questions. Just skip it and move to the next one.

We will ask you to fill in this information again at the end of your time with the Lifestyle Advisor Service as a way of monitoring how well the service is performing.
1. Physical activity
Work-related physical activity

I am not in employment (e.g. retired, retired for healt hreasons, unemployed, full-time carer etc)I spend most of my time at work sitting (such as in a office)I spend most of my time at work standing or walking.My work involves definite physical effort including handling of heavy objects and use of toolsMy work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc)
How much time do you spend each week in physical exercise such as swimming, jogging, aerobics, football, tennis, walking or gym workout?

NoneLess than 1 hourBetween 1 and 3 hoursMore than 3 hours
Do you track your steps, if yes, do you get to 10,000 steps?

YesNo
How would you describe your usual walking pace?
Use the comments box below if you wish to add further information relating to your current or desired physical activity levels. For example, you may like to highlight any factors which affect your ability to engage in physical activity.
2. Alcoholic drinking habits
How often do you have a drink containing alcohol?

NeverMonthly or less2-4 times per month2-3 times per week4+ times per week
How many units of alcohol do you drink on a typical day when you are drinking? (1 unit = ½ pint beer or cider = small glass of wine = single pub measure of spirit = 1 glass of port or sherry)

0-23 -45-67-910 +
How often have you had 6+ units if assigned female gender at birth or 8+ units if assigned male, on one occasion in the last year?

NeverLess than monthlyMonthlyWeekly(Almost) daily
Use the comments box below if you wish to add further information relating to your current or desired drinking habits. For example, you may like to include information on the types of drinks you prefer, or where and when you drink.
3. Smoking
Do you smoke cigarettes (including roll-ups)?
Do you want help to give up smoking?
Use the comments box below if you wish to add further information relating to your current or desired smoking habits
4. General Wellbeing
How well do you sleep on a scale of 1-10 (with 1 being the worst and 10 being the best)
How stressed are you on a scale of 1-10 (with 1 not at all stressed and 10 being the the most stressed)
What hobbies or activities do you enjoy?
Read the following statements and choose the most suitable response. This will give your Lifestyle Advisor valuable information about your current sense of wellbeing as well as gain an insight into improvements to wellbeing as a result of lifestyle change.
"I have been feeling optimistic about the future"

None of the timeRarelySome of the timeOftenAll of the time
"I have been feeling useful"

None of the timeRarelySome of the timeOftenAll of the time
"I have been feeling relaxed"

None of the timeRarelySome of the timeOftenAll of the time
"I have been dealing with problems well"

None of the timeRarelySome of the timeOftenAll of the time
"I have been thinking clearly"

None of the timeRarelySome of the timeOftenAll of the time
Use the comments box below if you wish to add further information relating to your general wellbeing or any other information you would like to share with the Lifestyle Advisor.
5. Social connections
Do you have a good support system?

YesNo
Tell us about your social support system
Should be Empty:

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