Pre-appointment Assessment Questionnaire


    Your weight and height

    Please record your recent weight and height

    Bloods

    Have you had any recent blood tests? Please attach the report, if available. 8mb max file size

    Medications

    What medications/ supplements are you currently taking?

    Other medical conditions

    What (if any) other medical conditions do you currently have?

    Current physical activity levels

    Please note down your usual planned and unplanned physical activity. Record intensity levels using L for low intensity, M for moderate & V for vigorous intensity*. Examples of unintentional physical activity include walking or cycling to work or shops, housework and gardening.

    Subjective assessment of stress levels

    How high are your levels of stress at present? (0- no stress at all; 10- very high levels of stress, impacting on work/relationships)

    Diet

    Please record your usual day of eating. Please include all food and drinks. It would be helpful to understand what you usually consume at each meal and snack time.

    Are you avoiding any foods/ drinks & if so, what is the reason for it?

    Do you have any diagnosed allergies?

    Your Goals

    Please describe three goals that you want to achieve through changing your diet &/or lifestyle habits.

    Thank you for your time.

    I have read and accept the privacy statement


    Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.


    HA Assessment


      At the time of Diagnosis

      Date diagnosed with HA

      Examination / Tests performed at diagnosis of HA

      Physical ExamVaginal Ultrasound (sonography)MRIBone Scan (DXA scan)Progesterone Challenge

      Attach blood results file (8mb max)

      Anthropometrics at diagnosis


      Physical activity at diagnosis

      Please note down your previous planned and unplanned physical activity, specifying duration. Record intensity levels using L for low intensity, M for moderate & V for vigorous intensity*. Examples of unintentional physical activity include walking or cycling to work or shops, housework and gardening.

      *Low: able to breathe and talk normally
      Moderate: feels somewhat hard. Here are clues that your exercise intensity is at a moderate level:
      • Your breathing quickens, but you're not out of breath.
      • You develop a light sweat after about 10 minutes of activity.
      • You can carry on a conversation, but you can't sing.
      Vigorous: feels challenging. Here are clues that your exercise intensity is at a vigorous level:
      • Your breathing is deep and rapid.
      • You develop a sweat after only a few minutes of activity.
      • You can't say more than a few words without pausing for breath.

      Subjective assessment of stress levels at diagnosis

      How high were your levels of stress at the time of diagnosis with HA? (0- no stress at all; 10- very high levels of stress, impacting on work/relationships)

      Medications

      What medications/ supplements were you taking at the time of diagnosis?

      Diet

      How would you describe your dietary intake at the time of diagnosis? Were you restricting any foods/ food groups or calories?

      Post Diagnosis

      Anthropometrics

      Please record your recent

      Bloods

      Have you had any recent blood tests? Please attach the report, if available. 8mb max file size

      Medications

      What medications/ supplements are you currently taking?

      Other medical conditions

      What (if any) other medical conditions do you currently have?

      Current physical activity levels

      Please note down your usual planned and unplanned physical activity. Record intensity levels using L for low intensity, M for moderate & V for vigorous intensity*. Examples of unintentional physical activity include walking or cycling to work or shops, housework and gardening.

      Subjective assessment of stress levels

      How high are your levels of stress at present? (0- no stress at all; 10- very high levels of stress, impacting on work/relationships)

      The Perceived Stress Scale

      Although some of the questions are similar, there are differences between them and you should treat each one as a separate question. The best approach is to answer fairly quickly. That is, don't try to count up the number of times you felt a particular way; rather indicate the alternative that seems like a reasonable estimate.
      For each question choose from the following alternatives:
      0 – never 1 - almost never 2 – sometimes 3 - fairly often 4 - very often

      1. In the last month, how often have you been upset because of something that happened unexpectedly?
      2. In the last month, how often have you felt that you were unable to control the important things in your life?
      3. In the last month, how often have you felt nervous and stressed?
      4. In the last month, how often have you felt confident about your ability to handle your personal problems?
      5. In the last month, how often have you felt that things were going your way?
      6. In the last month, how often have you found that you could not cope with all the things that you had to do?
      7. In the last month, how often have you been able to control irritations in your life?
      8. In the last month, how often have you felt that you were on top of things?
      9. In the last month, how often have you been angered because of things that happened that were outside of your control?
      10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

      Diet

      Please record your usual day of eating. Please include all food and drinks. It would be helpful to understand what you usually consume at each meal and snack time.

      Your relationship with food.

      Please tick any of the below if it applies to you:

      I usually describe a day of eating as either good or badIf I eat dessert, I make plans to exercise moreOnce I eat a forbidden food, I think, I blew it, and then I eat whatever I want, 
usually in large quantitiesI feel guilty if I don’t do my usual levels of exerciseIf I am planning to go out for dinner/ drinks, I cut back how much I eat during 
the day, regardless of my hunger and fullness levelsI will not let myself eat a particular snack/ meal if it exceeds a certain number 
of caloriesI weigh myself frequently

      Alcohol

      How many units of alcohol do you drink per week? If you are unsure, please use this link to help you Drink Aware

      Smoking

      Do you smoke?

      yesno

      I have read and accept the privacy statement


      Monika will always endeavour to reply to your message within 48 hours. If you have not received a reply to your message in that time, please check your spam/junk folder for the reply or contact her via monika(at)mbdietetics.com.