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NURSE SECTION
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BMI
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Normal BMI 18.5 - < 25
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Above Normal BMI =>25
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Overweight (BMI 25-29)
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Obesity Class 1 (BMI 30-34.9)
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Obesity Class 2 (BMI 35-39.9)
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Obesity Class 3 (BMI 40+)
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History
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Previous Dx Hypertension
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Elevated Blood Pressure
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Nicotine User
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Cigarettes
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Vape
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Chewing Tobacco
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Other
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Nicotine Cessation Intervention Done?
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Frequency of Use
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Do you feel this is a habitual problem?
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How motivated are you to quit?
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Do you have a good support system at home?
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Reasons for Quitting
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What type of counseling or intervention is being provided to you?
• • •
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Patient screened for food, housing, transportation, wellness, safety
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Scales
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Sleep Scales
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Epworth Scale
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1=Slight chance of dozing, 2=Moderate chance of dozing, 3= High chance of dozing
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Sitting and Reading
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Watching TV
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Sitting Inactive in a Public Place
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As a passenger in a car for an hr and no break
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Lying down to rest in the afternoon when you can
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Sitting and Talking to Someone
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Sitting quietly after lunch without alcohol
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In a car while stopped for few mins in traffic
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Total Score:
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Total item 1-17
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Stop / Bang
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Snoring, Tired, Observed Apnea, Blood Pressure
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Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
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Do you often feel tired, fatigued, or sleepy during daytime?
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Has anyone observed you stop breathing during you sleep?
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Do you have or are you treated for high blood pressure?
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BMI, AGE, Neck Circumference, Gender
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BMI more than 30?
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Age over 50 yrs old?
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Neck circumference greater than 16 inches?
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Gender Male?
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BEARS (Pediatric)
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Does my child have trouble going to bed? Or trouble falling asleep?
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Does my child often seem tired during the day?
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Does my child seem sleepy or groggy during the day?
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Does my child snoring? Loudly? Nightly?
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Is my child difficult to awake in the morning?
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Is anything else interrupting my child's sleep?
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Does my child gasp, stop breathing, or choke during the night?
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Does this allow my child to get enough sleep every day?
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How many hours of sleep does child need at this age?
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When does your child go to bed? Weekdays
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When does child get out of bed? Weekdays
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When does child go to bed? Weekends
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When does child get out of bed? Weekends
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Narcolepsy Scale
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How often are you unable to fall asleep?
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How often do you take a nap during the day?
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How often do you feel bad or not well rested in the morning?
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How often have you experienced weak knees/buckling of the knees during emotions like laughing, happiness, or anger?
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How often have you experienced sagging of the jaw during emotions like laughing, happiness, or anger?
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Sleep Questionnaire
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Reasons for Visit
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Normal Wake Time:
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Normal Bed Time
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Hours of Sleep per Night
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Previous Sleep Test
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If yes....Where & When
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Sleep Apnea [-]
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Obstructive Sleep Apnea
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Central Sleep Apnea
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Gasping during sleep [-]
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Shortness of Breath [-]
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Snoring [-]
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Asthma [-]
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Excessive Sleepiness [-]
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Seizures [-]
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Feel unable to move (paralyzed) when waking for falling asleep [-]
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Trouble falling asleep [-]
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Headaches [-]
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Frequent awakenings from sleep [-]
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Back Problems [-]
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Frequent Nightly Urinating [-]
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Neck Pain [-]
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Sleep Walking [-]
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Diarrhea [-]
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Sleep Talking [-]
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Trouble concentrating [-]
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Difficulty Swallowing [-]
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Nasal Problems [-]
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Smoke [-]
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High Blood Pressure [-]
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Drink Caffeinated Beverages [-]
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Heart Attack [-]
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Drink Alcohol [-]
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Heart Disease / Heart Failure [-]
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Dreams [-]
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Pre-Diabetic [-]
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Night Sweats [-]
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Diabetes [-]
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Leg movements / Leg kicks [-]
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Loss of muscle tone when extremely emotional [-]
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Naps [-]
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Heartburn / Acid Reflux [-]
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Act of out dreams [-]
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Depression [-]
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Use Alarm Clock [-]
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Anxiety [-]
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Weight Management Questionnaire
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Nutrition Assessment Questionnaire
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Why are you seeking a weight loss program?
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What lifestyle changes will you need to make to have success in your weight loss journey?
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How do you see yourself benefitting from successful weight loss?
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Special Diets
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Are you currently on a special diet?
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What is your currently prescribed diet?
• • •
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If Other, please describe
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Weight loss programs previously attempted (select all that apply):
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Plans to become pregnant?
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Food Allergies
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Please list any food allergies or intolerances:
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Diet History
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How long have you been overweight or obese?
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Were you overweight as a child?
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How much weight do you want to lose?
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Eating Disorders
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Have you ever received treatment for the following eating disorders?
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If answered other please list condition
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Have you ever used laxatives to control your weight?
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Do you find yourself eating large amounts of food when alone?
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Wake up in the middle of the night and eat?
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Wake up in the morning to find evidence you have eaten, but don't remember?
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Frequent skip meals?
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Frequent crave sweets during the day?
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Frequently fast as a part of your diet plan?
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Are a vegetarian?
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Drink alcohol?
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Feel that there are goods that you cannot live without?
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Experience problems with chewing or swallowing?
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If you checked yes on any of the above, please explain:
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Environmental Issues Affecting Your Weight
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Occupational (working around food/no time for lunch)?
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Sleep?
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Travel?
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Household?
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Shopping or cooking?
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Meals eaten away from home?
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I get my groceries at:
• • •
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Do you have a "good" supply (fruits, veggie, meat) for the month?
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How long does your "good" food supply last?
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If you do not have an adequate good supply for an entire month, what do you do?
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List the people who will be there to support you during your weight loss journey:
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Readiness For Change
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Weight Loss: Check the statement below that BEST pertains to you right now:
• • •
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Exercise: Check the statement below that BEST pertains to you right now:
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Exercise Questionnaire
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Do you have doctor-ordered restrictions on exercise?
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What is currently limiting your physical activity?
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Do you have a current exercise routine? If yes, explain:
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What types of exercise have you performed in the past that helped you with weight loss?
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Do you have a gym membership, and are you likely to use it?
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What type of exercise equipment is available to you at home?
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On a scale from 1-10, how motivated to exercise are you? (1-lowest, 10-highest)
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If you are not currently exercising, do you have a plan to get started? If so, please explain:
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