1/11/2014

MOVE!23 Questionnaire - Healthcare Provider's Report

Healthcare Provider Report

(Approximate Age: 29)

*RC: E57.316861C

Date: 1/11/2014

* RC = Retrieval Code for veterans receiving care in the Department Of Veterans Affairs. This report is for use by healthcare providers to assist individuals with weight management. The MOVE!23 Patient Questionnaire identifies self-reported personal barriers for weight management and physical activity. Healthcare providers should review the MOVE!23 Patient Report with patients before they begin new weight management or physical activity programs. The Provider Report complements the MOVE!23 Patient Report, which provides information tailored just for them. The MOVE!23 Healthcare Provider Report identifies: If there is a need for further clinical evaluation and/or physical activity precautions Personal barriers to changing diet and/or physical activity behavior Specific patient handouts based on patient reported barriers, available on the MOVE! website Other self-management support materials for patients available on the MOVE! website Information regarding MOVE! program development and additional resources for healthcare providers and patients are available at the following sites:
WWW.MOVE.VA.GOV WWW.HEALTHIERUSVETERANS.VA.GOV

Key findings and further suggestion:

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MOVE!23 Questionnaire - Healthcare Provider's Report

Individual's Stage of Readiness to Change: Action (Ready) Review summary below. Individual has "Red Flags" that require further evaluation and/or treatment prior to participation in a weight management program. Review summary below.

MOVE!23 Questionnaire Summary

Importance, Confidence, and Readiness to Change

The individual checked that he/she is actively working on weight management at this time. Congratulate the individual and support self-efficacy. If importance or confidence is rated in the mid or low range, ask the individual what it might take to rate them 1-2 points higher. See MOVE! Handout B05 - YES NOW YOU A RE DOING IT Red Flags for Further Evaluation Prior to Weight Management Participation The individual is reporting the following: Back pain or spinal disc disease

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MOVE!23 Questionnaire - Healthcare Provider's Report

The individual should check with the primary care provider before doing strength or flexibility exercises. This includes exercises using free weights, specialized machines, or resistance type exercises like sit-ups. The individual is reporting problems with or a history of an eating disorder such as binge eating, bulimia, or anorexia. The individual should check with their primary care provider before beginning any weight management program. The individual is reporting the following: Too much stress Depression Anxiety problems or nervousness Family or relationship problems Binge eating pattern: 2 - 4 times per week Poor control of any of these issues may make changing behaviors related to weight management more difficult for the individual. Discuss with individual whether further evaluation and treatment for any of these issues is needed and/or wanted. The following MOVE! Handouts may help: B12 - EMOTIONSAND YOUR WEIGHT, B28 - DEALING WITH STRESS A NXIETY A ND DEPRESSION, B29 - TAKE CONTROL O F YOUR THOUGHTS FEELINGS A ND B EHAVIOR , B16 - TEMPTED, B24 - CONTROL YOURSELF . Weight History, Expectations, and Prior/Current Weight Management Strategies Individual reports current health to be: Poor Individual reports weight gain pattern as: I have gained and lost weight many times over the years (yo-yo). M01 - S KIP THE FAD D IET The individual reports belief in ability to lose 51 - 100 lbs in one year. Weight loss expectations may be unrealistic. Remind individual of the health benefits of even small amounts of weight loss. In general, people can safely lose -2 pounds a week, on average, if they work at it. See MOVE! Handout S02 S ET YOUR WEIGHT LOSS G OALS.
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MOVE!23 Questionnaire - Healthcare Provider's Report

The individual reports using the following strategies to manage weight: strategy
Some form of dieting, that is eating differently from the way you usually eat for the sake of losing weight Avoiding particular foods or food groups Physical exercise, such as walking, swimming or calisthenics Prepackaged meals M eal replacements in bar, powder, liquid, tablet or water form Fasting for 24 hours or longer Skipping meals Any other kind of weight loss program that does NOT provide comprehensive treatment (dietary changes, physical activity, and behavioral counseling) Keeping a log or journal for eating or exercise Taking an over the counter (OTC) medication; vitamin, mineral, or nutrient supplement; herbal supplement; naturopathic or alternative medicine preparation or supplement to lose weight Smoking to control weight

previously used

currently using

You may want to discuss with the individual what worked and what didnt work for him/her in the past and the pros and cons of various methods he/she has tried or is currently using. Behavioral Summary Weight Perception and Satisfaction Individual is Very dissatisfied with the appearance of his/her body. Help the individual to focus on positive features rather than dwell on the negatives. See the MOVE! handout B08 - BODY IMAGE for more information. For some patients, dissatisfaction with body appearance can be used to increase motivation and strengthen commitment. Can rely on friends and family for support: Not at all. See MOVE! Handout B27 - INVOLVING OTHERSIN YOUR WEIGHT C ONTROL
P ROGRAM
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MOVE!23 Questionnaire - Healthcare Provider's Report

Reasons given by individual for his/her overweight/obesity:

MO VE! handouts are available for som e of the se issue s

Eating because of emotions or stress - B12 , B28 , B29 Family or relationship problems Eating too much - B24 , B16 Poor food choices or habits - N01 - A LL FOODS C AN FIT Difficulty with self control - B24 , B16 Quitting tobacco use - B23 - QUIT S MOKING GAIN WEIGHT Medications led to weight gain - M03 - MEDICATIONS C AN C AUSE WEIGHT GAIN

Nutrition Summary Reported Barriers to Changing Eating Habits:

MO VE! handouts are available for som e of the se issue s

Too little time to prepare and eat healthy food - N18 - MAKE IT QUICK, B30 - NOT ENOUGH TIME Too little money to buy healthy food - N06 - EATING WELL ON A BUDGET Difficulties such as stress or depression - B12 , B28 , B29 Current Eating Patterns: Individual may be eating too quickly. B26 - S LOW D OWN YOU EAT TOO FAST Individual may be eating out or buying food to go frequently. This often can lead to overeating or eating higher calorie foods. N25 - RESTAURANT TIPS, N07 - FAST FOOD A LTERNATIVES
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MOVE!23 Questionnaire - Healthcare Provider's Report

Physical Activity Summary Current Physical Activity Levels 30-59 minutes of Moderate Activity on 4 days per week.
Mode rate - Mode rate physical activitie s cause light swe ating and a slight to m ode rate incre ase in bre athing or he art rate . e x am ple s include brisk walk ing, bicycling, vacuum ing, garde ning, and golfing without a cart.

20-29 minutes of Vigorous Activity on 2 days per week

Vigorous - Vigorous activite s cause he avy swe ating and large incre ase s in bre athing or he art rate . Ex am ple s include running, ae robic classe s, he avy yard work , and brisk ly swim m ing laps.

Reported Barriers to Increasing Physical Activity:

MO VE! handouts are available for som e of the se issue s

Too little time - P01 - BARRIERS TO PHYSICAL A CTIVITY, P11 - LACK OF TIME FOR EXERCISE, B30 Lack of support or encouragement from others - B27 Difficulties such as stress, depression, etc. - B12 , B28 , B29 Pain - B10 - C OPING WITH PAIN Back problems - B09 - C OPING WITH MEDICAL PROBLEMS, P22 - INCREASING PHYSICAL A CTIVITY FOR V ETERANS WITH PHYSICAL OR MEDICAL LIMITATIONS, P21 - A CTIVITY LIMITATIONS FOR C ERTAIN MEDICAL C ONDITIONS Too tired Job or work schedule - P01 , P11 , B30

Summary of Suggested Handouts

B05 - YES NOW YOU A RE D OING I T B08 - B ODY I MAGE B09 - C OPING WITH MEDICAL P ROBLEMS B10 - C OPING WITH P AIN
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MOVE!23 Questionnaire - Healthcare Provider's Report

B12 - EMOTIONSAND YOUR WEIGHT B16 - TEMPTED B23 - Q UIT S MOKING G AIN WEIGHT B24 - C ONTROL YOURSELF B26 - S LOW D OWN YOU EAT TOO FAST B27 - I NVOLVING O THERSIN YOUR WEIGHT C ONTROL P ROGRAM B28 - D EALING WITH S TRESS A NXIETY A ND D EPRESSION B29 - TAKE C ONTROL O F YOUR THOUGHTS FEELINGS A ND B EHAVIOR B30 - NOT ENOUGH TIME M01 - S KIP THE FAD D IET M03 - MEDICATIONS C AN C AUSE WEIGHT G AIN N01 - A LL FOODS C AN FIT N06 - EATING WELL O N A B UDGET N07 - FAST FOOD A LTERNATIVES N18 - MAKE I T Q UICK N25 - R ESTAURANT TIPS P01 - B ARRIERS TO P HYSICAL A CTIVITY P11 - LACK O F TIME FOR EXERCISE P21 - A CTIVITY LIMITATIONS FOR C ERTAIN MEDICAL C ONDITIONS P22 - I NCREASING P HYSICAL A CTIVITY FOR V ETERANS WITH P HYSICAL O R MEDICAL LIMITATIONS S02 - S ET YOUR WEIGHT LOSS G OALS

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