Lifestyle Management Forms

Appendix
G
LIFESTYLE MANAGEMENT FORMS
3.1 Assessment Ruler 6.3 Tips to Reduce Stress
3.2 Nutrition Counseling—Lifestyle 6.4 Prochaska and DiClemente’s

Management Agreement Spiral of Change
3.3 Student Nutrition Counseling Assignment— 6.5 Frequent Cognitive Pitfalls

Lifestyle Management Agreement 7.1 Benefits of Regular Moderate
4.1 Client Assessment Questionnaire Physical Activity
4.2 Food Record 7.2 Physical Activity Log
4.3 24-Hour Recall/Usual Diet Form 7.3 Physical Activity Options
4.4 Food Frequency Questionnaire 7.4 Physical Activity Medical Readiness Form
4.5 Food Group Feedback Form 7.5 Physical Activity Status
4.6 Anthropometric Feedback Form 7.6 Medical Release
4.7 Client Concerns and Strengths Log 7.7 Physical Activity Feedback Form
4.8 Client Progress Report 8.1 Interview Checklist
5.1 Eating Behavior Journal 8.2 Counseling Responses

Competency Assessment
5.2 Counseling Agreement
9.1 Registration for Nutrition Clinic
6.1 Symptoms of Stress
6.2 Stress Awareness Journal
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Lifestyle Management Form 3.1
A s s e ssmen t R u ler
VERY 12
11
10
4
For readiness to change
3 1 = not at all 12 = very
For adherence to dietary goals

1 = never 12 = always
2 For confidence in making a lifestyle change
1 = not at all 12 = very
For degree of importance for making a lifestyle change

1 1 = not at all 12 = very
NOT AT ALL
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N u t ri t i o n Cou n selin g —
L i f es t yl e M a nag emen t Ag reem ent
Thank you for your interest in the nutrition counseling clinic offered by ___________. It is designed to provide
a mutually beneficial experience for both students and volunteer adult clients. You will work one on one with
an advanced nutrition counseling student for ____ sessions, each one lasting approximately one hour. During
the registration process, clients are assigned a counselor, a counseling room, and meeting times. The counsel-
ing sessions provide clients an opportunity to explore and find solutions for nutrition and weight issues. At the
same time, students will be working on their nutrition counseling skills. Although students will be following a
well-defined counseling guideline, each session will be tailored to their client’s needs. Students can only assist
clients in achieving weight loss if the client is overweight by National Institutes of Health standards. Normal
and underweight clients can still take part in the program with the goal of improving the quality of their diet.
Your student counselor will use a client-centered, motivational approach during his or her sessions with
you. This means your counselor will work collaboratively with you to explore your nutrition and weight
issues, brainstorm resources and solutions, and help you set achievable goals each week. Students will ask
you questions about your health and family history as well as present day food habits. Two of the nutrition
assessment forms will be given to you at registration. You can look at them before signing this form. Students
will have a variety of tools at their disposal including videos, food models, and educational handouts.
Students are encouraged to engage their clients in hands-on experiences. Therefore, at times your counseling
session may take place in a grocery store, the student cafeteria, or the gym. Possibly you and your coun-
selor will follow the walk-about map of our campus.
Physical activity is an important part of fitness and weight management. Experience has shown that our
clients have a variety of orientations to this topic. If you are already very active in this area, you will be en-
couraged to continue your program. However, if exercise has not been a joyful experience, you will be in-
vited to explore this issue. As long as you have no medical problem and you are ready to take action,
weekly activity goals will be developed with you. For appropriate clients, we have a structured walking
protocol that can be followed.
The student may speak occasionally with his or her graduate mentor or instructor about you. The student will
write a report about the counseling experience. This report is only shared with the course instructor. Your coun-
selor may give a case study presentation about you to the nutrition counseling class, but at no time in these
presentations will your name be used. In all other respects, information you give the student will be held in ab-
solute and strictest confidence.
We thank you very sincerely for your willingness to participate and for your help in the education of fu-
ture nutrition counselors. If you have any questions or problems during this project, please call the course
instructor, ___________________________________________, at ___________________________________________.
I, _____________________________, have read and understand the above statement and agree to
Print your name here
meet with ______________________________ at agreed times and places on the registration form.
__________________________________________________________ ________________________________________
Your signature here Today’s date
__________________________________________________________ ________________________________________
Counselor signature here Today’s date
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St u de n t Nu trition Cou n selin g

A s s i g n m en t—Lif esty le
M a n a ge men t Ag reemen t
Thank you for your willingness to participate in the nutrition counseling clinic offered by
________________________. This interview is designed to provide nutrition counseling students
interviewing experience. The objective is for the student to work on counseling skills, gather
information about the health problem, and learn something about your health issues. While
discussing your situation, you may receive some benefit by clarifying your health problem(s)
to yourself, and possibly you will make a resolution to take a new action regarding the
problem; however, this experience is not designed to be an intervention.
After this meeting, the student will be required to write a report about his or her find-
ings. This report is only shared with the course instructor. It is possible that information in
the report will be shared with other students during classroom discussions; however, at no
time will your name be used in those discussions. In all other respects, the information you
give will be held in absolute and strictest confidence.
We thank you very sincerely for your willingness to participate and for your help in the
education of future nutrition counselors. If you have any questions or problems during this
project, please call the course instructor, __________________, at _________________.
I, _____________________________, have read and understand the above statement.

Print your name here
__________________________________________________ _______________________________
Your signature here Today’s date
__________________________________________________ _______________________________
Counselor’s signature here Today’s date
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C l i e n t Assessm en t
Q u estion n aire
D E M O G R A P H I C D ATA
Name Date:
Address Home telephone:
Office telephone:
Fax: E-mail
Sex: M F Age: Birth date Height Weight
HEALTH HISTORY
1. What medical concerns (e.g., pregnancy), if any, do you have at the present time?
2. Indicate whether you have had blood relatives with any of the following problems:
Cancer ■ yes ■ no High blood pressure ■ yes ■ no

Diabetes ■ yes ■ no Osteoporosis ■ yes ■ no
Heart disease ■ yes ■ no Thyroid disorder ■ yes ■ no
High cholesterol ■ yes ■ no
3. Do you have complaints about any of the following?

Appetite Constipation Menstrual difficulties
Bleeding gums Diarrhea Seeing in dim light
Bruising Edema Sudden weight change
Chewing or swallowing Indigestion Stress
4. Do you use tobacco in any way? ■ yes ■ no How much?

Did you recently stop smoking? ■ yes ■ no
5. Do you enjoy physical activity? ■ yes ■ no Explain:
6. List any food allergies or intolerances.
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DRUG HISTORY
List any prescribed, over-the-counter, herbal, or vitamin/mineral supplements you take.
DIET HISTORY
1. Do you follow a special dietary plan, such as low cholesterol, kosher, or vegetarian?
2. Have you ever followed a special diet? Explain:
3. Do you have any problems purchasing foods that you want to buy?
4. Are there certain foods that you do not eat?
5. Do you eat at regular times each day? ■ yes ■ no How often?
6. Identify any foods you particularly like.
7. Do you drink alcohol? ■ yes ■ no How often?
8. What change would you like to make?

■ Improve my eating habits ■ Improve my activity level
■ Learn to manage my weight ■ Improve my cholesterol/triglyceride levels
■ Other
9. Please add any additional information you feel may be relevant to understanding
your nutritional health.
10. To tailor your counseling experience to your needs, it would be useful to know
your expectations. Please check one of the following to indicate the amount of
structure you believe meets your needs:
■ Just tell me exactly what to eat for all my meals and snacks. I want a detailed
food plan. Example: 3⁄4 cup corn flakes, 1 cup skim milk, 6 oz. orange juice,
1 slice whole wheat toast, 1 teaspoon margarine
■ I want a lot of structure but freedom to select foods. I want to use the exchange
system. Example: 1 milk, 2 starch, 1 fruit, and 1 fat exchange
■ I want some structure and freedom to select foods. I want to use a food group
plan. Example: 1 serving of dairy foods, fruits, and fat and oil group; 2 serv-
ings of grains
■ I don’t want a diet. I just want to eat better. I will just set food goals each week.
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SOCIOECONOMIC HISTORY
1. Circle the last year of school attended:

12345678 9 10 11 12 1234 M.A. Ph.D.
Grade School High School College
Other type of school
2. Are you employed? Occupation
3. How many people in your household? Ages?
4. Present marital status (circle one):

Single Married Divorced Widowed Separated Engaged
5. Do you have a refrigerator? Stove?
6. Who prepares most of the meals in your home? Shopping?
7. Do you use convenience foods daily? ■ yes ■ no
8. How often do you eat out? Where?
9. Have you made any food changes in your life you feel good about? ■ yes ■ no
10. Who could support and encourage you to make these changes?
E D U C AT I O N I N T E R E S T S
What information would you like from your counselor?

■ Supermarket shopping tour ■ Eating out ■ Exercise
■ Weight management ■ Portion size ■ Alcohol calories
■ Healthy food preparation ■ Eating less fat ■ Meal planning
■ Fiber ■ Walking program ■ Snack foods
■ Food labels ■ Other
Thank you for your willingness to share this information and to take part in the Nutrition Clinic. We look
forward to working with you to make lifestyle changes to meet your food and fitness objectives.
256
F o o d R ec ord
Name: Date:
• Complete this form as accurately as possible, using the examples as a guide.
• Use only one form per day. Do not put anything on this form that pertains to
another day.
• Record all foods and beverages, including water, you consumed from the time you
wake up to the time you go to bed.
TIME FOOD / DRINK TYPE PREPARATION AMOUNT
8:00 A.M. Bagel Cinnamon raisin Toasted Half

8:00 A.M. Milk 1% fat Fresh 8 ounces
Noon Chicken Leg and thigh Fried 1 each
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24- Hou r R ec all/

U s u al Diet Form
Date:____________ Day of the week:___________________
• Record food and fluid intake from time of awakening until the next morning.
NUMBER OF SERVINGS FROM EACH GROUP
Fats,
FOOD AND DRINK CONSUMED Milk Meat Fruits Veggies Breads Sweets
Standard for Adults 2–3 2–3 2–4 3–5 6–11 None
Time Name and Type Amount
TOTALS
*EVALUATION
*Evaluation: L low A adequate E excessive
258
Fo o d G ro up S erv in g S iz es
Us i n g t h e F o o d Gu id e Py ra mi d S erv i ng S i z es
BREADS, CEREALS, AND OTHER GRAIN PRODUCTS
1 slice bread
1
⁄2 c cooked cereal, rice, or pasta
1 oz. ready-to-eat cereal
1
⁄2 bun, bagel, or English muffin
1 small roll, biscuit, or muffin
3 to 4 small or 2 large crackers
V E G E TA B L E S
1
⁄2 c cooked or raw vegetables
1 c leafy raw vegetables
1
⁄2 c cooked legumes
3
⁄4 c vegetable juice
FRUITS
typical portion: 1 medium apple, banana, or orange, 1⁄2 grapefruit, or 1 melon wedge
3
⁄4 c juice
1
⁄2 c berries
1
⁄2 c diced, cooked, or canned fruit
1
⁄4 c dried fruit
M E AT, P O U L T R Y, F I S H , A N D A L T E R N AT E S
2 to 3 oz. lean, cooked meat, poultry, or fish (total 5–7 oz. per day)
Count as 1 oz. meat or 1⁄3 serving: 1 egg, 1⁄2 c cooked legumes, 4 oz. tofu, 2 tbs. nuts,
seeds, or peanut butter
MILK, CHEESE, AND YOGURT
1 c milk or yogurt
2 oz. process cheese food
11⁄2 oz. cheese
FAT S , S W E E T S , A N D A L C O H O L I C B E V E R A G E S
• Foods high in fat include margarine, salad dressing, oils, mayonnaise, sour cream,
cream cheese, butter, gravy, sauces, potato chips, and chocolate bars.
• Foods high in sugar include cakes, pies, cookies, doughnuts, sweet rolls, candy, soft
drinks, fruit drinks, jelly, syrup, gelatin, desserts, sugar, and honey.
• Alcoholic beverages include wine, beer, and liquor.
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F o o d Frequ en c y
Q u estion n aire
SERVINGS PER WEEK

SERVINGS PER DAY
NEVER or RARELY
SERVING SIZES FOOD GROUP
1 slice bread Refined Grains—white bread, pasta, cereals ❑

1 c dry cereal
1
⁄2 c cooked rice, pasta, or cereal
Whole Grains—whole-wheat bread, brown rice, ❑
oatmeal, bran cereal
1
⁄2 bun, bagel, or English muffin
1 small roll, biscuit, or muffin
1 c raw leafy vegetable Vegetables ❑

1
⁄2 c cooked or raw vegetables
6 oz. vegetable juice
6 oz. fruit juice Fruits ❑

1 medium fruit
1
⁄4 c dried fruit
1
⁄2 c fresh, frozen, or canned fruit
8 oz. milk Dairy—low-fat or fat-free ice cream, milk, cheese, ❑

1 c yogurt yogurt; frozen yogurt
11⁄2 oz. cheese
2 oz. process cheese
Dairy—whole milk, regular cheese, regular ice cream ❑
3 oz. cooked meats, poultry, or fish

Meats, Poultry, Fish—lean ❑
Meats, Poultry, Fish—high-fat: sausage, cold ❑
cuts, spareribs, hot dogs, eggs, bacon
1
⁄3 c or 11⁄2 oz. nuts Nuts, Seeds, and Dry Beans ❑
2 tbsp. or 1⁄2 oz. seeds
1
⁄2 c cooked dry beans
4 oz. tofu, 1 c soy milk
2 tbsp. peanut butter
1 tbsp. regular dressing Fats and Oils ❑

2 tbsp. light salad dressing
1 tsp. oil
1 tbsp. low-fat mayonnaise
1 tsp. margarine, butter
8 oz. lemonade Sweets ❑

11⁄2 oz. candy
8 oz. soda
12 oz. beer, 4 oz. wine Alcohol ❑

1 shot hard liquor
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F o o d G ro u p Feed bac k Form
YOUR SERVINGS RECOMMENDED SERVINGS
NEVER OR
FOOD GROUP NUMBER RARELY PYRAMID DASH
Refined Grains—white ❑
bread, pasta, cereals
Whole Grains—whole- ❑ 6–11 7–8

wheat bread, brown rice,
oatmeal, bran cereal
Vegetables ❑ 3–5 4–5
Fruits ❑ 2–4 4–5
Dairy—low-fat, fat-free, ❑ 2 2–3

low-fat ice cream or
frozen yogurt
Dairy—whole milk, ❑ — —
regular ice cream,
regular cheese
Meats, Poultry, Fish—lean: ❑ 2–3 2 or less

poultry (no skin), egg whites
Meats, Poultry, Fish— ❑ — —

high fat: hot dogs,
cold cuts, sausage
Nuts, Seeds, ❑ 4–5

and Dry Beans per week
Fats and Oils ❑ Use sparingly 2–3
Sweets ❑ Use sparingly 5 per week
Alcohol ❑ Use sparingly
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A n t hrop ometric
F e e d bac k Form
Volunteer’s Measurements Standard
Actual weight Insurance table
Dietary guidelines
Hamwi ideal body weight
BMI desirable weight
Body mass index Desirable 19–25
Waist circumference High risk males, 102 centimeters (40 inches);

females, 88 centimeters (35 inches)
Waist-to-hip ratio Increased risk males 1.0; females, 0.8
262
C l i e nt Con c ern s
a n d S tren g th s Log
1. List all concerns expressed by your client or identified by you.
2. Write NC (no control) next to of all concerns over which you or your client have
no control.
3. Categorize in the following chart the remaining concerns over which there is some
degree of control and as a result could be addressed by a goal:
Nutritional Behavioral Exercise
263
4. List strengths and skills.
5. Categorize the strengths and skills in the following chart:
Nutritional Behavioral Exercise
6. What strengths and skills can be used to address the concerns? List them in the follow-
ing chart.
Possible Inter vention

Strengths and Skills Concerns Strategies
264
C lien t Prog ress R epor t
Name:
Date Issue Action Outcome (Anticipated) Follow-up*

265
* O ongoing; A achieved; U unrealistic.

E a t i n g B eh av ior J ou rn al
Name:
Day/Date: Physical Activities:1
Location/ Foods and Beverages Consumed Degree of

Time Place Amounts/Description Hunger 2 Social Situation 3 Comments 4
1Include type of activities and minutes engaged in the activities.

2Use the following rating scale: 0 = not hungry; 1 = hungry; 2 = very hungry.
3Indicate activities and who you were with, if anyone.
4Record significant thoughts (“I’m doing great”; “I am a loser”); feelings (angry, happy, worried); concerns (“Maybe I should have had the turkey sandwich”)
Source: Adapted from Pastors et al., Facilitating Lifestyle Change: A Resource Manual. Chicago: American Dietetic Association; © 1996. Reprinted
with permission.
266
C o u n s e l i n g Ag reem en t
Name: Date:
My plan is to do the following:
This activity will be accomplished by
My reward will be (specify when, where, and what)
Your signature Date
Counselor’s signature Date
267
S ym p t om s of S tress
Physical Symptoms Emotional Symptoms
• Muscular tension • Anxiety

• Headaches • Frequent crying
• Insomnia • Irritability
• Twitching eyelid • Frustration
• Fatigue • Depression
• Backaches • Worrying
• Neck/shoulder pain • Nervousness
• Digestive disorders • Moodiness
• Teeth grinding • Anger
• Changes in eating/sleep patterns • Self-doubt
• Sweaty palms • Resentment
Mental Symptoms Social Symptoms
• Short concentration • Loneliness

• Forgetfulness • Nagging
• Lethargy • Withdrawal from social contact
• Pessimism • Isolation
• Low productivity • Yelling at others
• Confusion • Reduced sex drive
Sources: Adapted from Women First Health Care, www.womenfirst.com/ and Goliszek A, 60 Second Stress Management. Far Hills, NJ: New Horizon Press;
1992.
268
Lifestyle Management Forms 6.2
S t re s s A waren ess J ou rn al
Name: ______________________________________________________ Date: _______________
Time Symptom of Stress Activities Internal Self-Talk
269
T i p s t o R ed u c e S tress
• Learn to say no. Don’t overcommit. Delegate tasks at home and work.
• Organize your time. Use a daily planner. Prioritize your tasks. Make a list and a realistic
timetable. Check off tasks as they are completed. This gives you a sense of control for
overwhelming demands and reduces anxiety.
• Be physically active. Big-muscle activities, such as walking, are the best for relieving
tension.
• Develop a positive attitude. Surround yourself with positive quotes, soothing music, and
affirming people.
• Relax or meditate. Schedule regular massages, use guided imagery tapes, or just take
ten minutes for quiet reflection time in a park.
• Get enough sleep. Small problems can seem overwhelming when you are tired.
• Eat properly. Be sure to eat five servings of fruits and vegetables and three servings of
whole grains every day. Limit intake of alcohol and caffeine.
• To err is human. Don’t create a catastrophe over a mistake. Ask yourself what will be
the worst thing that will happen.
• Work at making friends and being a friend. Close relationships don’t just happen.
Compliment three people today. Send notes to those who did a good job.
• Accept yourself. Appreciate your talents and your limitations. Everyone has them.
• Laugh. Look at the irony of a difficult situation. Watch movies and plays and read
stories that are humorous.
• Take three deep breaths.
• Forgive. Holding onto grudges only causes you more stress and pain.
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Pr o ch a s ka an d DiClem en te’s
S p i ral of Ch an g e
Source: Prochaska JO, Norcross JC, DiClemente CC, Changing for Good. New York: Avon; © 1994, p. 49. Used with permission.
271
Frequ en t
C o gn itiv e Pitf alls
1. Overgeneralizing. One small event is generalized as representative of a larger picture. “I tried
walking once, but I got a blister. That just goes to show that I wasn’t made for exercise.”
2. Only perfect is OK. A single slip means the attempt was a total failure, there is no middle
ground. “I had potato chips. This isn’t working. I give up.”
3. Once started, no use stopping. This type of cognitive distortion results in eating a whole
container, once a single piece is consumed and often occurs when particular foods are consid-
ered off-limits. “Since I ate one potato chip, the harm has already been done. I might as well eat
the whole bag.”
4. Awfulizing. An anticipated negative consequence or an actual negative event is considered a ca-
tastrophe leading the way to panic or depression and a delusion that the situation is too awful
to do anything about it. “My blood pressure is high. This is a horrible, dreadful, terrible situation
I am in.”
5. Deserving. Food is frequently used as a reward for a job well done or for nurturing after a diffi-
cult experience. “I deserve a chocolate sundae after having such a rough day.”
6. Lapses are due to lack of will power. A momentary indulgence is not considered a key learning
opportunity but is attributed to a lack of will power, a personal failing. Once will power has
failed, loss of control is an absolute fact. “I will never be able to change. I just don’t have any
will power. It’s just no use.”
7. Distorting. By dwelling on a single negative detail, the total picture is distorted. “If I can’t have
cotton candy at the circus, it is not worth going to the circus.”
8. Transforming positive into negative. Accomplishments are considered a quirk, positives are ex-
plained away for one reason or another. “Yes, I did have fruit for dessert this time but that was
because it was on the dessert tray and I didn’t want the waiter to go back to the kitchen for the
chocolate cake. We didn’t have time to wait.”
9. Trivializing. Positives are considered insignificant. “The only thing I have been able to do right is
eat a fruit everyday and that doesn’t amount to much.”
10. Anticipating the worst. Negative predictions are made and accepted as fact. “If I ate more fruits
and vegetables, my blood pressure would not come down. It wouldn’t work for me.”
11. Exaggerating. Difficulties are blown out of proportion to their importance. “There was no skim
milk at the store. I can’t take this. Forget this food plan business.”
12. Focusing on negative feedback. Negative feedback is considered significant and positive feed-
back is rejected. “The woman at the gym said I should be ashamed of the way I look. She is right,
not the people in my support group who say I should accept and love myself.”
13. Absolutizing. Individuals criticize themselves and others with demanding words such as should,
ought, must and have to. Inability to live up to an irrational standard leads to feeling anxious and de-
pressed and sets the stage for relapse. “I really must eat fish and oatmeal everyday.”
14. Vilifying. An individual is denounced after an inadequate performance. Once labeled there is no
reason to expect a better performance in the future. “I am a jerk for eating that candy. I am
worthless.”
Sources of data: Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression. New York: Guilford; 1979:261. Burns DD. Feeling Good. New York:
Avon Books, 1999:42–43. Ellis A, Harper RA, A Guide to Rational Living. Hollywood, CA; Wilshire Book Company; 1997. Snetselaar LG. Nutrition
Counseling Skills for Medical Nutrition Therapy. Gaithersburg, MD: Aspen; 1997:88–89.
272
B e n ef its of
R e g u l ar M ode rate
P h ys i c al Ac tiv ity
➤ Reduces risk of dying prematurely
➤ Reduces risk or aids in the management of

• heart disease,
• diabetes,
• high blood pressure,
• colon cancer,
• strong bones, and
• falls.
➤ Improves mood, self-esteem, and self-image
➤ Increases energy
➤ Maintains weight or aids loss of weight
➤ Maintains function and preserves independence in older adults
273
P h ys i cal Ac tiv ity Log
• Record all physical activity for a week. Remember to include regular daily activities
such as climbing stairs, gardening, and walking to the office from a parking lot.
• Include all forms of physical fitness activities including stretching, weight lifting,
balancing, and aerobic movement.
Day of the Week Type of Activity Amount of Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
274
Ph y sic al
A ct i v ity O p tion s
➤ Look for Everyday Opportunities
Short bursts of activity throughout the day make a difference.
• Use steps instead of elevators or escalators.
• Park your car in a distant section of the parking lot.
• Leave work five minutes later. Take a walk around the building.
• Get off the train or bus one stop earlier and walk the rest of the way.
• Take a walk during lunch.
• March, stretch, or do squats while brushing your teeth.
• Pace around the house or do arm curls with a can of food while talking on the phone.
• Jump rope, stretch, jog in place, or lift weights while watching TV.
• Be prepared. Keep walking shoes in your car or in your desk.
• Take your bike with you to a conference and explore the local scenery before
driving home.
➤ Plan a Daily Routine

Think about cost, convenience, and bad weather options when planning a program.
Look for creative ways to keep the activities enjoyable.
• Schedule time for physical activity. Write it in your calendar.
• Vary the physical activities. Plan to bike one day a week, jog two days a week, and
go to the gym three days a week.
• Join a walking club, a biking club, and so forth.
• Add variety to the activity. Have several walking trails, ask a friend to join you in your
walks, or listen to music or recorded books during your walks.
➤ Plan Physically Active Leisure-Time Events

Look for activities the whole family can enjoy.
• Have a family baseball or soccer game.
• Plan a bike tour, mountain hike, or canoe trip.
• Explore a cave.
Need more ideas? The American Heart Association has an inexpensive paperback with
hundreds of simple, affordable, and practical ideas. Fitting in Fitness (Times Books–Random
House, 1997) is available in bookstores.
275
P h ys i ca l Ac tiv ity Med ic al

Re a d in ess Form
Regular physical activity is fun and healthy and being more active is very safe for most
people. Checking with your doctor is always a good idea before starting to become much
more physically active. The questions below can help guide you on the necessity of getting
a physician’s opinion. Your best guide when answering the questions is to use common
sense. Please read the questions carefully and check YES or NO.
YES NO
❑ ❑ 1. You have a heart condition, and your doctor recommends only medically
supervised physical activity.
❑ ❑ 2. During or right after you exercise, you frequently have pains or pressure
in the left or midchest area, left side of your neck, or left shoulder or arm.
❑ ❑ 3. You have developed chest pain within the last month.
❑ ❑ 4. You tend to lose consciousness or fall over because of dizziness.
❑ ❑ 5. You feel extremely breathless after mild exertion.
❑ ❑ 6. Your doctor recommended that you take medicine for high blood pressure
or a heart condition.
❑ ❑ 7. You have bone or joint problems.
❑ ❑ 8. You have a medical condition or other physical reason not mentioned

here that might need special attention in an exercise program (such as
insulin-dependent diabetes).
❑ ❑ 9. You are more than 25 to 30 pounds overweight.
❑ ❑ 10. You are a man over the age of 40 or a woman over the age of 50, have
not been physically active, and are planning a vigorous exercise program.
Source: American Heart Association. Fitting in Fitness. New York: Times Books; 1997, p.33. Reprinted with permission. The American Heart Association
checklist was developed from several sources, particularly the Physical Activity Readiness Questionnaire, British Columbia Ministry of Health, Department
of National Health and Welfare, Canada (revised 1992).
276
If you answered YES to one or more questions:

Talk with your doctor by phone or in person BEFORE you start becoming much more phys-
ically active or BEFORE you have a fitness appraisal.
• You may be able to do any activity you want—as long as you start slowly and build up
gradually. Or, you may need to restrict your activities to those that are safe for you.
Talk with your doctor about the kinds of activities you wish to participate in and follow
his or her advice.
• Develop an exercise plan with the aid of an exercise specialist.
If you answered NO honestly to all the questions, you can be reasonably sure that you can:
• Start becoming much more physically active—begin slowly and build up gradually.
This is the safest and easiest way to go.
• Take part in a fitness appraisal—this is an excellent way to determine your basic fitness
so that you can plan the best way for you to live actively.
DELAY BECOMING MUCH MORE ACTIVE:

• If you are not feeling well because of a temporary illness such as a cold or a
fever—wait until you feel better; or
• If you are or may be pregnant—talk to your doctor before you start becoming
more active.
Please note: If your health changes so that you then answer YES to any of these
questions, tell your fitness or health professional. Ask whether you should change
your physical activity plan.
277
P h ys i ca l Ac tiv ity S tatu s

Moderate physical activity includes swimming, cycling, dancing, gardening, domestic and
occupational activities at an intensity level equivalent to 30 minutes of brisk walking.
Vigorous physical activity refers to activities that make you work as hard as jogging for
20 minutes; generally you sweat and feel out of breath, and your heart rate increases.
Activities in this category include running, lap swimming, jumping rope, and cross-country
skiing.
Muscular strength activities include weight training using dumbbells or machines or
resistance activities using elastic bands.
Flexibility training activities include stretching, yoga, and T’ai Chi Chuan.
Leisure Time Physical Activity Status
Muscular Strength Activity (Check if the statement applies to you.)

❑ I am involved in muscular strength activities consisting of at least one set of 8 to 10 exer-
cises (8–12 repetitions of each) that conditions the major muscle groups at least 2 times per
week.
Flexibility Training Activity (Check if the statement applies to you.)
❑ I am involved in flexibility exercises that stretch the major muscle groups at least 2 times per
week.
Moderate or Vigorous Activity (Circle one number only.)
1. I do not exercise or walk regularly now, and I do not intend to start in the near future.
2. I do not exercise or walk regularly, but I have been thinking of starting.
3. I am trying to start to exercise or walk. (or) During the last month I have started to exercise
or walk on occasion (or on weekends only).
4. I am doing vigorous or moderate exercise, less than 3 times per week (or moderate
exercise less than 2 hours per week).
5. I have been doing moderate or vigorous exercise, 3 or more times per week (or more than
2 hours per week) for the last 1 to 6 months. If this is the case, put a check next to either
of the following if they apply to you:
❑ I have been doing at least 30 minutes of moderate activity or 20 minutes of vigorous
activity most days of the week.
❑ I have been doing at least 20 minutes of vigorous activity 3 or more days of the week.
Source: This form is based on What is Your PACE SCORE assessment form. Long BL et al., Project PACE Physician Manual. Atlanta, GA: Centers for
Disease Control, Cardiovascular Health Branch, 1992. Physical activity standards are from American College of Sports Medicine Position Stand, Med Sci
Sports Exerc. 1998:30(6):975–991 and U.S. Department of Health and Human Services, Healthy People 2010.
278
M e di c al R elease
[Name and address of program]
Your patient has enrolled in our nutrition counseling lifestyle management program. We
have asked this person to seek medical consultation to evaluate whether there should be
any limitations as to his or her involvement in our clinic. If a client wishes to lose weight, a
program is designed that allows for modest weight loss of one to two pounds per week.
Students counsel clients under the supervision of food and nutrition faculty. Please com-
pletely read the following statements and sign the form if you believe your client can safely
participate in a lifestyle management program to alter eating and exercise behaviors.
Date:
This is to certify that I have examined the person named here:
Name:
Address:
City, State, ZIP
This person was found to be in satisfactory health. There are no reasons to prohibit this
person from participating in a lifestyle management program that advocates changes in
eating behaviors and modest exercise goals tailored to the client’s level of readiness.
Health Practitioner
Address
For further information, please contact at
279
P h ys ic al Ac tiv ity
F e e d bac k Form
The following contains your evaluation of the physical activity assessment form you com-
pleted. Do not be surprised if you do not meet all the standards set by national organiza-
tions—most North Americans do not. One consequence of recent technological advances
has been to decrease the need to move. This is a serious concern for our health. As evi-
dence has been accumulating about the benefits of regular physical activity, several gov-
ernmental and health agencies have issued official statements and/or instituted national
programs to combat this problem. These include
• American Medical Association,
• American Heart Association,
• Centers for Disease Control,
• American College of Sports Medicine,
• National Institutes of Health, and
• Office of the Surgeon General and Health Canada.
Many Americans may be surprised at the extent and strength of the evidence linking
physical activity to numerous health improvements.
—David Satcher, director of the Centers for Disease Control and Prevention*
Benefits of regular moderate exercise
➤ Reduces your risk or aids in the management of

• heart disease,
• diabetes,
• high blood pressure,
• colon cancer, and
• strong bones.
➤ Improves your mood, self-esteem, and self-image.
➤ Increases energy.
➤ Maintains or aids in loss of weight.
➤ Maintains function and preserves independence in older adults.
*Foreword, Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: Department of Health and Human Services; 1996.
280
Physical Activity Standard † Standard Met Standard Not Met
Muscular strength: Engage in strength activities ❑ ❑

consisting of one set of eight to ten exercises
(8–12 repetitions of each) that conditions the major
muscle groups at least 2 times per week.
Flexibility: Engage in activities that stretch major ❑ ❑
muscle groups at least 2 times per week.
Endurance: Engage in at least 30 minutes of ❑ ❑
moderate activity or 20 minutes of vigorous activity
most days of the week.
Endurance: Engage in at least 20 minutes of ❑ ❑
vigorous activity 3 or more days of the week.
Motivation Level Implication
Level 1—Not ready ❑ Would you consider learning more about how moder-
ate physical activity could help your health?
Level 2—Unsure ❑ For some reason you are not sure that you are ready to
begin a physical activity program. Your counselor will
explore your ambivalence with you to see whether you
are ready to make plans to increase your physical
activity level.
Level 3—Ready ❑ Great—you are ready to begin or increase your activ-
ity level. Your counselor can provide you with resources
to aid in developing a plan.
Level 4—Active ❑ Congratulations—you are already actively involved in
a physical activity program. Your counselor will review
with you the standards set by authorities. If you do
not meet all of them, you may wish to make some
alterations.
Physical Activity Readiness
❑ Talk to your doctor before becoming much more physically active or having a fitness
appraisal as indicated by the following:
❍ Medical Readiness Questions ❍ Woman over age 50 ❍ Man over age 40
❑ Delay an increase in physical activity due to pregnancy or illness.
Standards are based on American College of Sports Medicine Position Standards, 1998 and Healthy People 2010 physical activity goals.
Note: Reevaluate readiness if you experience dizziness, chest pain, undue shortness of breath, difficulty breathing, or unusual discomfort after
beginning an exercise program.
281
I n t e rview Ch ec k list
Interviewer: Observer: Date:
Goal of the interview:
I. FLOW OF THE INITIAL INTERVIEW

A. Involving Phase
1. Greeting Yes ❑ No ❑
a. Verbal greeting Yes ❑ No ❑
b. Shakes hands Yes ❑ No ❑
2. Introduction of self Yes ❑ No ❑
3. Attention to self-comfort—other obligations finished or planned
for a later time, attention focused (self-evaluation only) Yes ❑ No ❑
4. Attention to client’s comfort—physical comfort, noise and
visual distractions minimized Yes ❑ No ❑
5. Small talk, if appropriate Yes ❑ No ❑
6. Establishes counseling objectives Yes ❑ No ❑
a. Opening question—What brings you here today? Yes ❑ No ❑
b. Establishes client’s long-term objectives Yes ❑ No ❑
c. Explains counseling process Yes ❑ No ❑
d. Discusses weight monitoring, if appropriate Yes ❑ No ❑
7. Establishes agenda Yes ❑ No ❑
8. Transition statement—Now that we have gone over the basics
of the program, we can explore your needs in greater detail. Yes ❑ No ❑
B. Exploration-Education Phase
1. Reviews completed assessment forms Yes ❑ No ❑

2. Compares assessment to a standard, point by point,
nonjudgmental Yes ❑ No ❑
3. Asks client thoughts about comparison Yes ❑ No ❑
4. Segment summary—identifies problems, reiterates
self-motivational statement, checks accuracy Yes ❑ No ❑
5. Asks client whether he or she would like to make changes Yes ❑ No ❑
6. Assesses motivation—use a ruler to determine readiness
to change Yes ❑ No ❑
7. Tailors educational experiences to client needs Yes ❑ No ❑
Source: This evaluation form is based on the Brown Interview Checklist, Brown University School of Medicine, Novack, DH, Goldstein, MG, Dub CE,
1986. Used with permission.
282
C. Resolving Phase
Level 1 (0–4 on ruler)
1. Raises awareness—discusses benefits of change Yes ❑ No ❑

2. Raises awareness—personalizes benefits Yes ❑ No ❑
3. Asks key open-ended questions regarding importance
of change Yes ❑ No ❑
4. Segment summary Yes ❑ No ❑
5. Offers advice, if appropriate Yes ❑ No ❑
6. Expresses support Yes ❑ No ❑
1. Raises awareness—discusses benefits of change

and diet options Yes ❑ No ❑
2. Asks key open-ended questions regarding confidence in
ability to change Yes ❑ No ❑
3. Asks key open-ended questions to identify barriers Yes ❑ No ❑
4. Examines pros and cons Yes ❑ No ❑
5. Imagines the future Yes ❑ No ❑
6. Explores past successes Yes ❑ No ❑
7. Explores support networks Yes ❑ No ❑
8. Summarizes ambivalence Yes ❑ No ❑
1. Praises positive behaviors Yes ❑ No ❑

2. Explores change options Yes ❑ No ❑
a. Asks client’s ideas for change Yes ❑ No ❑
b. Uses an options tool, if appropriate Yes ❑ No ❑
c. Explores concerns regarding selected option Yes ❑ No ❑
3. Explains goal setting process Yes ❑ No ❑
4. Identifies a specific goal from a broad goal—
uses small talk, explores past experiences, builds on past Yes ❑ No ❑
5. Goal is achievable, measurable, under client control,
stated positively Yes ❑ No ❑
6. Designs a plan of action Yes ❑ No ❑
a. Investigates physical environment Yes ❑ No ❑
b. Examines social support Yes ❑ No ❑
c. Examines cognitive environment; explains coping
talk, if needed Yes ❑ No ❑
d. Defines a tracking technique Yes ❑ No ❑
e. Client verbalizes goal Yes ❑ No ❑
7. Writes down goal Yes ❑ No ❑
283
D. Closing Phase
1. Supports self-efficacy Yes ❑ No ❑

2. Reviews issues and strengths Yes ❑ No ❑
3. Uses relationship-building response—respect Yes ❑ No ❑
4. Restates food goal Yes ❑ No ❑
5. Reviews next meeting time Yes ❑ No ❑
6. Shakes hands Yes ❑ No ❑
7. Expresses appreciation for participation Yes ❑ No ❑
8. Uses relationship-building responses—support and partnership Yes ❑ No ❑
II. INTERPERSONAL SKILLS

A. Facilitation (Attending) Skills
1. Eye contact—appropriate length to enhance client comfort Yes ❑ No ❑

2. Uses silences to facilitate client’s expression of thoughts
and feelings Yes ❑ No ❑
3. Open posture—arms uncrossed, facing client F ❑ P ❑ No ❑
4. Head nod, “Mm-hm,” repeats client’s last statement F ❑ P ❑ No ❑
F = Frequently; P = Partially
B. Relationship Skills (Conveying Empathy)
1. Reflection—restates the client’s expressed emotion or inquires

about emotions F ❑ P ❑ No ❑
2. Legitimation—expresses understandability of client’s emotions Yes ❑ No ❑
3. Respect—expresses respect for the client’s coping efforts or
makes a statement of praise Yes ❑ No ❑
4. Support—expresses willingness to be helpful to client
addressing his or her concerns Yes ❑ No ❑
5. Partnership—expresses willingness to work together with client Yes ❑ No ❑
F = Frequently; P = Partially
III. PATIENT RESPONSES OFTEN SOMETIMES SELDOM
A. Client freely discusses his or her concerns. ❘____________❘___________❘

B. Client appears comfortable and relaxed. ❘____________❘___________❘
C. Client appears engaged in the counseling session. ❘____________❘___________❘
D. Client freely offers information about his or her ❘____________❘___________❘
condition and life context.
IV. GENERAL COMMENTS
284
C o u n s e l in g R esp on ses
C o m pe t e n c y Assessmen t
Audio- or videotape a counseling session, and listen to the tape several times to complete
the following assessment:
• Track the number of times you made each response by placing slash marks next to the
name of the response. Note that this is an evaluation of your responses, not your
client’s responses.
• For each category of responses, give an example from the tape. In cases where the
particular response category was not demonstrated on the tape, write an example that
may have been effective with your client and then complete the category evaluation.
• Select an intent and focus of the response. You may wish to review a discussion of
these topics in Chapter 2.
• Indicate the effectiveness of your particular response, and explain why it was or was
not effective. For responses that do not receive the most effective rating, write alterna-
tive responses that you believe would have worked better.
• Some of your responses may not fit any of the categories. This assessment covers many
basic counseling responses, but it is possible that some of your statements do not ap-
pear to fit into any of the categories. If that is the case, such material would not be
evaluated. The following is an example of a competency evaluation for one response:
Example
Questions ///
Example What brings you here? Are you looking to lower your blood pressure?
Intent (circle one): To acknowledge To explore To challenge
Focus (circle one): information experience feelings thoughts behaviors
❑ Effective ❑ Somewhat Effective ❑ Not Effective Explain I asked

two questions at the same time. I made an assumption that the main issue was blood pressure.
Alternative Response What brings you here today?
1. Attending
Example
❑ Effective ❑ Somewhat Effective ❑ Not Effective Explain
Alternative Response
285
2. Reflection (Empathizing) __________

Example
3. Legitimation __________
Example
4. Respect __________
Example
5. Personal Support __________

Example
6. Partnership __________
Example
286
7. Mirroring (Parroting) __________

Example
8. Paraphrasing __________
Example
9. Giving Feedback (Immediacy) __________

Example
10. Questioning __________

Example
11. Clarifying (Probing, Prompting) __________

Example
287
12. Noting a Discrepancy (Confrontation, Challenging) __________

Example
13. Directing (Instructions) __________

Example
14. Advice __________

Example
15. Allowing Silence __________

Example
16. Self-Referent __________

Example
288
Re g i s t ra t i o n f or Nu trition Clin ic
Counselor Participant
Name Name
Business telephone Business telephone
Best times to call: Best times to call:
Home telephone Home telephone
Best times to call: Best times to call:
E-mail E-mail
Fax Fax
Your meeting day is: Location of meetings:
Your meeting time is: Room number:
Length of meetings is approximately one hour. If welcome packet forms have not been
completed previous to the first session, the first counseling session may take an extra
twenty minutes.
The dates of your four meetings are as follows:
• Please complete two copies of this agreement form. The client copy should be given to
the participant, and the clinic copy should be given to the counselor.
• Thank you for your interest in our program. Please note that any cancellations of meet-
ings should be made directly between each participant and counselor.
• If you have any questions about the program, please call the instructor,
, at .
289

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Appendix

3.1 Assessment Ruler 6.3 Tips to Reduce Stress

3.2 Nutrition Counseling—Lifestyle 6.4 Prochaska and DiClemente’s

3.3 Student Nutrition Counseling Assignment— 6.5 Frequent Cognitive Pitfalls

4.2 Food Record 7.2 Physical Activity Log

4.3 24-Hour Recall/Usual Diet Form 7.3 Physical Activity Options

4.5 Food Group Feedback Form 7.5 Physical Activity Status

4.6 Anthropometric Feedback Form 7.6 Medical Release

4.8 Client Progress Report 8.1 Interview Checklist

5.1 Eating Behavior Journal 8.2 Counseling Responses

For adherence to dietary goals

For degree of importance for making a lifestyle change

St u de n t Nu trition Cou n selin g

I, _____________________________, have read and understand the above statement.

Cancer ■ yes ■ no High blood pressure ■ yes ■ no

3. Do you have complaints about any of the following?

4. Do you use tobacco in any way? ■ yes ■ no How much?

5. Do you enjoy physical activity? ■ yes ■ no Explain:

6. List any food allergies or intolerances.

List any prescribed, over-the-counter, herbal, or vitamin/mineral supplements you take.

2. Have you ever followed a special diet? Explain:

4. Are there certain foods that you do not eat?

5. Do you eat at regular times each day? ■ yes ■ no How often?

6. Identify any foods you particularly like.

7. Do you drink alcohol? ■ yes ■ no How often?

8. What change would you like to make?

1. Circle the last year of school attended:

Other type of school

2. Are you employed? Occupation

3. How many people in your household? Ages?

4. Present marital status (circle one):

5. Do you have a refrigerator? Stove?

6. Who prepares most of the meals in your home? Shopping?

7. Do you use convenience foods daily? ■ yes ■ no

8. How often do you eat out? Where?

What information would you like from your counselor?

TIME FOOD / DRINK TYPE PREPARATION AMOUNT

8:00 A.M. Bagel Cinnamon raisin Toasted Half

24- Hou r R ec all/

NUMBER OF SERVINGS FROM EACH GROUP

Standard for Adults 2–3 2–3 2–4 3–5 6–11 None

Time Name and Type Amount

SERVINGS PER WEEK

1 slice bread Refined Grains—white bread, pasta, cereals ❑

1 c raw leafy vegetable Vegetables ❑

6 oz. fruit juice Fruits ❑

8 oz. milk Dairy—low-fat or fat-free ice cream, milk, cheese, ❑

3 oz. cooked meats, poultry, or fish

1 tbsp. regular dressing Fats and Oils ❑

8 oz. lemonade Sweets ❑

12 oz. beer, 4 oz. wine Alcohol ❑

F o o d G ro u p Feed bac k Form

YOUR SERVINGS RECOMMENDED SERVINGS

Whole Grains—whole- ❑ 6–11 7–8

Vegetables ❑ 3–5 4–5

Fruits ❑ 2–4 4–5