The Patient Intake Questionnaire

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To gather information about a patient's past obesity-related history, patients are requested to come for the appointment 15 minutes early to complete paperwork. This is similar to what is asked for new patient appointments, well baby examinations, or women's annual examinations.

The value of the intake survey is threefold. First, it contains a tremendous amount of patient information related to the patient's weight loss expectations, review of comorbidities, previous weight loss attempts, family obesity history, dietary lifestyle, self-efficacy assessment, and the possibility of eating disorders (Figure 8.3). Second, the wide array of data the survey contains helps validate coding for the visit. Third, the survey reflects a serious effort on the physician's part to understand the patient's obesity condition as a potential medical-legal

Please Answer the Following Questions

1. How much weight do you want to lose?_

2. What is the heaviest you've ever weighed?_At what age?_

3. What is the most amount of weight you've ever lost during one attempt?_

4. What diet plan or plans have you tried?_,_

5. How long did it take to lose the weight?-

6. How much weight did you lose while on the diet plans?_lbs.

7. What is the lowest weight you have maintained for 1 year as an adult over age 21?_lbs.

8. Have you taken over-the-counter weight loss medications? Y/N

9. Have you taken prescription weight loss medications? Y/N

10. Do you currently or have you had problems with any of the following:

a. Gallbladder Y/N

b. Stomach Reflux Y/N

c. Diabetes or High Blood Sugar Y/N

d. Heart disease Y/N

e. Joint pain Y/N

g. High Blood Pressure Y/N

h. High cholesterol Y/N

i. Depression Y/N

j. Sleep Apnea or snoring Y/N k. Relationships with other Y/N

11. Do you like to exercise? Y/N

- If yes, what do you do?_How many times per week?_

12. Have you ever hurt yourself while exercising? Y/N

13. Please list medical problems you have (ex. diabetes, high blood pressure)

14. Is anyone in your household overweight? Y/N - If yes, who are they?_

15. Who does the grocery shopping for you?_

16. How many meals per week do you eat at home?_

17. Do you eat breakfast during the week? Y/N

18. Do you eat lunch during the week? Y/N - If yes, where do you eat?_

What is your favorite food(s) for lunch?

Figure 8.3. Obesity questionnaire.

19. Typically what time of day do you eat dinner?_

- During the week, is it the same time of the day? Y/N

- How many dinner meals do you eat out of the home each week?_

20. Do you have a favorite evening or night time snack(s)? Y/N

21. Do you eat more food on weekends? Y/N

- Are there any 'special' foods or drinks you wait until the weekend to enjoy? (ex. ice cream, beer, snacks) Y/N If yes, what are they?_

22. How confident are you that you can complete a daily food log where you write down the calories from every thing you eat for 10 days? (circle number below)

0123456789 10

Not at all confident Moderately Confident Very confident

23. Binge eating is consuming large quantities of food in a short period of time, even when no longer hungry or already feeling 'full.' Some people say they' just cannot stop eating, even though they are not hungry.

a. Are there times when you binge eat? Yes No (If no, then stop here.)

b. If yes, how many times per week does it occur?_

c. Does it occur just at particular times, like weekends or evenings? Yes No d. Does it occur when you are emotional (sad, lonely, depressed)? Yes No e. Do you think you need help with your binge eating? Yes No

Figure 8.3. Continued defense in case the patient or someone else should file suit against the physician for not treating the patient's obesity. With those points in mind, let's look at some of the key questions in the survey.

Question 1 asks the most obvious question in the physician's mind: How much weight does the patient want to lose? The patient's expectation for the program is tied to this question. For those who want to lose over 100 lb, then the next question has to do with time. How long does the patient think it will take to lose the 100 lb? If the response is unreasonable or unhealthful, then the physician may try to spread out the patient's timeframe to 1 or 2 years. If the patient insists on a lot of weight loss over a short period of time, then the physician can direct the conversation towards helping the patient understand that the amount of weight loss in the time desired is unhealthy. If this is the case, then the physician can tell the patient that now may not be the time to participate in a weight loss program because failure is likely to occur with such a high expectation over such a short period of time.

Question 3 asks what is the most amount of weight the patient has ever lost during any one attempt. Like the first question, this is a red flag. If the answer is none, yet the patient has tried a number of different programs, then the physician needs to explore with the patient why this time might be different. The physician need not lose heart with those who failed in the past because most patients try to lose weight a number of times before becoming successful. Persistence is an important characteristic of success with long-term weight loss.

A number of patients will have lost a considerable amount of weight in the past. It is not uncommon for patients to say they lost 60 to 100lb in the past. The problem is the weight came back, which means the patient did not have a weight maintenance program in place to keep the weight off, or an overwhelming obstacle like divorce, loss of employment, or illness came into the patient's life, and they regained the weight. For patients who have lost a considerable amount of weight in the past, the physician can use this fact to quickly explore how they did it and encourage them that this is a good sign with regard to their ability to stay focused on their weight loss goal.

Question 10 is a quick review of obesity-associated illnesses. A quick review of the yes responses enables the physician to see the impact of obesity on the patient's health. If any particular comorbidity, like depression, is not being adequately treated, then the physician can shift the appointment to addressing that particular concern. Certain comorbidites, if not properly treated, will hamper the patient's ability to lose weight.

Question 11 asks if the patient likes to exercise. Not surprisingly, many patients who say "no" don't mind walking. Patients recall unpleasant memories of high school physical education or times when they tried to go to fitness gyms. Therefore, the physician might consider using the term physical activity instead of exercise to avoid the negative associations many patients have with exercise.

According to the Surgeon General's report on physical activity, about 25% of the American population do not like to exercise [1]. The heavier the patient, the more likely he or she does not exercise. Some obese patients need to lose weight before they can safely participate in any exercise program. The disabled who are obese may not be able to participate in an exercise program. What does the physician say to these patients?

When discussing this question, the physician can reassure patients that exercise is not critical for losing weight, though it is statistically important for keeping the weight off. For instance, though 91% of the members of the National Weight Control Registry (NWCR) exercise regularly, that still leaves 9% who lost weight and kept it off who claim not to exercise [2]. Clearly it is harder to lose weight and keep it off without exercising, but it is not impossible. Caloric reduction is more critical than increasing one's physical activity level. Patients can always consume more calories through eating than they can burn through physical activity. Caloric reduction is the key to weight loss for the majority of obese patients, not more exercise. The patient's answer to this question helps the physician direct the conversation regarding exercise.

Questions 13 through 21 provide patient-specific information that tells the physician about the patient's eating style. The physician should not make value judgments concerning particular foods people choose to eat or try to correct an imbalanced approach to food. An opportunity to help improve the patient's dietary choices comes with the second appointment.

Question 22 asks the patient how confident he or she is of being able to keep a 10-day food diary. Those who circle a number below 4 are not very confident they can record their food intake for 10 days. Lack of confidence in recording a food diary is a strong predictor of not being able to successfully commit to a 6-month weight reduction program. Patients who circle 1 or 2 should probably consider not trying to lose weight at this time. Avoidance of failure at trying to lose weight is an important concern for the physician. Obese patients are in the physician's office because they tried at least once to lose weight and failed. Experiencing failure again should be avoided if at all possible. A low number for this question is an opportunity for the physician to discuss this concern with the patient.

Question 23 is important in helping identify a possible binge eating disorder. The prevalence of binge eating disorder (BED) is not known. Earlier studies by Spitzer et al. suggested 29% of people seeking obesity treatment have a BED [3]. More recent studies suggest the prevalence is between 8.9% and 18.8% [4,5]. Whatever the actual percentage, the reality is that many patients who want obesity treatment in the primary care physician's office have a BED.

A physician has three options to help possible BED patients. First, if qualified, treat the patient. Second, make available self-help books like Peter Miller's Binge Breaker [6]. Third, refer to a psychologist who treats eating disorders. Whichever approach is used, it is critical to address the possibility of eating disorders during the first visit. This section of the intake survey makes certain this occurs and sets the stage for a possible intervention in helping the patient deal with this behavior.

Reviewing the intake survey with the patient takes about 5 minutes. If there are any serious concerns, like untreated depression or a possible eating disorder, then the physician can refocus the discussion towards that concern. If there are no major concerns, then the discussion between the physician and patient turns to the form called the Battle in the Mind (Figure 8.4).

Motivators

1.

Look better in clothes

1 2

3

4

5

6

7

2.

Improve self-confidence

1 2

3

4

(5)

6

7

3.

Be able to play with kids

1 2

3

4

5

6

(7)

4.

Health concerns

1 2

3

4

(5)

6

7

5.

Improve adult relationship

1 2

3

4

5

6

®

6.

1 2

3

4

5

6

7

Barriers

1.

TV (snacking)

1 2

3

4

(5)

6

7

2.

Time management problems

1 2

3

4

(5)

6

7

3.

Fast food consumption

1 2

3

4

5

6

7

4.

Impulsive eating

1 2

3

4

5

6

7

5.

Foods family likes

1 2

3

4

5

(6

7

6.

Working third shift

1 2

3

4

5

6

7

Figure 8.4. An example of the Battle in the Mind for one patient (Copyright © 2001 Dr Thomas McKnight).

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