• Patient Lifestyle Assessment and Progress Chart

    Copyright© E. Anthony Allen 2008

    This response sheet is designed to assist the doctor in your follow-up, as well as to help you in your own self-assessment. Insert relevant numbers or Y = yes, N = no. Use average for numbers as applicable.

  • Date
     - -

  • Regular Exercise

  • Relaxation Exercise

  • Recreational Activities

  • Current regular hobby

  • Reaching out to Friends and/or Relatives (for mutual support) 
      per day /  per week /   per month

  • Voluntary Service
      per month   per quarter 

  • Reaching out-Spiritual

  • Makes use of activities for fellowship, education and support at place of worship?

  • Nutritional Self-Care

  • Uses most groups of plant based food, and mostly unprocessed
  • Eats 5-7 servings of vegetables and fruits daily
  • Eats more vegetables than starches
  • Generally avoids processed or refined grain products
  • Mostly avoids red meats
  • Mostly avoids other parts of non-organically grown chicken, except breast
  • Includes mostly: fish or plant based protein products as dietary protein
  • Rows
  • Drinks 6-8 glasses of water daily
  • Healthy snacks between meals
  • Rows
  • Sunlight: 15 minutes daily
  • In appropriate weight range for my height:
  • Safe sex Practiced: (Condom, or abstinence, or mutual fidelity)
  • HIV status known
  • Substance Avoidance (e.g. cigarettes, excess alcohol, drugs)
  • Most of Socio-economic habits: -improving productivity skills -budgeting -saving -planning
  • Annual check up completed (if over 25 years):
  • Rows
  • Informative Reading
  • Centering Time
  •  
  • Should be Empty: