Andrew Appleton MD

Cardiometabolic Health – Lifestyle Medicine Referral Request

By completing this form, you are requesting a referral to the Cardiometabolic Health – Lifestyle Medicine Program. The program is run virtually and is available for residents anywhere in Ontario. **Please view this VIDEO for instructions on how to take neck, waist, and hip measurements. Prior to completing the form, please make sure you have all of your prescribed and over-the-counter medications/vitamins/supplements available for documentation. You will also be asked to include information about health conditions that run in your family. It can be helpful to touch base with family members first to ensure you have the best possible information.

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Personal Information

Name(Required)

First Last

Date-of-Birth(Required)

YYYY slash MM slash DD

Phone(Required)

Email(Required)

Health Card Number(Required)

Version Code(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Sex at birth(Required)

Male

Female

Prefer not to say

Current gender(Required)

Woman

Man

Transgender woman

Transgender man

Non-binary

Prefer not to say

Other

Which of the following best describes you?(Required)

Asian or Pacific Islander

Black or African Canadian

Hispanic or Latino

Indigenous (First Nations, Metis, or Inuit)

White or Caucasian

Multiracial or Biracial

A race/ethnicity not listed here

Prefer not to answer

Information about ethnicity helps us better understand your genetic predisposition and risk for certain conditions.

I currently have a family doctor or nurse practitioner who I see for primary care.(Required)

Yes

Name of family doctor or nurse practitioner.

First Last

I would like my current primary care provider to be copied on consultation and assessment notes.

Yes

Medical History

Please select ALL conditions or diagnoses that you have experienced.(Required)

Overweight/Obesity

Pre-diabetes

Diabetes

High blood pressure

High cholesterol

Heart disease/Heart attack

Stroke

Sleep apnea

Kidney disease

Liver disease

Autoimmune disease

Arthritis

Cancer

None of the above

Please list any other diagnoses or conditions you currently have.

Add new line for each diagnosis. If none, write “none.”

Please list any prescription or over-the-counter medications or supplements you currently take.(Required)

Add new line for each medication. If none, write “none.”

Please list any important diagnoses in your family members (parents, siblings).(Required)

Add a new line for each family member. Please consider heart disease, diabetes, cancer, dementia, or any conditions you think are relevant. Include the family member (eg. mom, dad, brother) and their approximate age at diagnosis. If none, write “none.”

Please select ALL symptoms you experience on a regular basis.(Required)

Daytime fatigue/sleepiness

Chest pain

Shortness of breath

Joint pain

Abdominal pain

Loose bowels

Constipation

Night sweats (eg. soaking bed sheets)

Unintentional weight loss

Indigestion/reflux

Heart racing/palpitations

None of the above

Other

Specify 'Other' symptom(s)

Have you ever been pregnant?

Yes

How many pregnancies have you had?

Please consider all pregnancies, including those that may not have resulted in a live birth.

How many live births have you had?

Please select ALL conditions that occurred during ANY of your pregnancies.

High blood pressure

Gestational diabetes (high sugar after glucose tolerance test)

Pre-eclampsia

Protein in your urine

Birth weight over 9 pounds

None of the above

Please select the current status of your menstrual cycle.

I have a regular cycle

I have an irregular cycle

I believe I am perimenopausal

I am post-menopause

I have had a hysterectomy

Please select your current status of hormone therapy

I don’t use any hormonal or intrauterine therapy right now

I use oral/transdermal/injectable hormonal contraception

I use an intrauterine device for contraception

I use hormone therapy for treatment of menopausal symptoms

Please describe your reason for wanting to join the CMBH – Lifestyle Medicine Program.(Required)

You can use this space to explain any of your selections above regarding diagnoses or symptoms. Please also let us know you main concerns for your health, if any, and your future health goals.

Stress

Over the past past two weeks, how often have you been bothered by having little interest or pleasure in doing things?(Required)

Not at all

Several days

More than half the days

Nearly every day

Over the past past two weeks, how often have you been bothered by feeling down, depressed, or hopeless?(Required)

Not at all

Several days

More than half the days

Nearly every day

Over the past past two weeks, how often have you been bothered by feeling nervous, anxious, or on edge?(Required)

Not at all

Several days

More than half the days

Nearly every day

Over the past past two weeks, how often have you been bothered by not being able to stop or control worrying?(Required)

Not at all

Several days

More than half the days

Nearly every day

What strategies for stress reduction do you regularly use? Check ALL that apply.(Required)

Mindfulness techniques

Meditation

Breathing exercises

Nature

Yoga

Exercise

Time management

Counselling/Therapy

Cognitive behavioural therapy

None of the above

Sleep

Thinking of the past 7 days, please rate the quality of your sleep overall (0 is terrible, 10 is excellent)(Required)

Consider the number of hours, ease of falling asleep, number of awakenings, and how refreshed you felt.

What time do you normally go to bed?(Required)

Answer based on nights during the work week.

Hours

Minutes

AM/PM

What time do you normally wake up?(Required)

Hours

Minutes

AM/PM

Do you often feel tired, fatigued, or sleepy during the day?(Required)

Yes

To the point where you could fall asleep while sitting, driving, or having a conversation.

Are you known to snore loudly?(Required)

Yes

Do you often wake up suddenly feeling out of breath or gasping?

Yes

Has anyone observed you stop breathing during sleep?

Yes

Do you drink any caffeine-containing beverage in the afternoon?(Required)

This includes coffee, tea, energy drinks, pop/soda.

Yes

Does your job involve shift-work or nighttime hours?(Required)

Yes

Please describe your shift-work schedule.

Fitness

On average, how many DAYS per WEEK do you engage in moderate to strenuous physical activity?(Required)

This could include formal exercise, swimming, biking, brisk walking, or playing sports. Please do NOT include job-related physical work when considering your response.

On average, how many MINUTES per DAY do you exercise at this level?

How many DAYS per WEEK do you engage in muscle-strengthening exercises, such as body weight exercises or resistance training?(Required)

Do you currently have a gym/fitness membership?(Required)

Yes

Name of gym or fitness club

Do you have exercise/fitness equipment at home?(Required)

Yes

Please select ALL equipment you have access to at home.

Treadmill

Stationary bike

Rowing machine

Elliptical

Dumbbells

Kettle bells

Resistance bands

Medicine balls

Pull-up/Chin-up bar

Squat rack

Bench

Plyo box

Olympic bar and plates

Home gym system (eg. Bowflex or similar)

Do you have any injuries, chronic pain, or physical limitations that affect the type of exercise you can perform?(Required)

Yes

Please describe any injuries, chronic pain, or physical limitations that we should know about when planning an exercise program.

Please include previous major injuries or surgeries on your upper limbs, lower limbs, or back. You may also want to include chronic pain or arthritis that limits your physical function.

Nutrition

What dietary pattern best describes how you currently eat?(Required)

This does not mean you are currently on a “diet”. We are just trying to get a sense of what is normal for you.

Mediterranean

Low carb/Atkins

Keto

Carnivore

Paleo

Low fat

Vegan

Vegetarian

Pescatarian

Gluten free

I don’t follow any dietary pattern

Other

Over the past TWO WEEKS, how often have you consumed fast food, sugary drinks (pop, soda, fruit juices), or packaged/pre-made food?(Required)

not at all

several days

more than half the days

nearly every day

On average, how many servings of whole fruit and vegetables do you eat (one serving is about a handful and does not include fruit juice)?(Required)

2-3

4-5

Have you ever been diagnosed with an eating disorder?(Required)

Yes

What was the diagnosis?

Have you recovered from this eating disorder or are you currently receiving treatment/counselling?

Yes

Please describe any food allergies, intolerances, or aversions in the box below.(Required)

If none, write, “none.”

Substances

Did/Do you smoke tobacco products (cigarettes, cigars, etc.)?(Required)

Never

Past user

Current user

When did you quit?

How many years did you smoke altogether?

Give your best estimate.

Which of the following best describes your use of alcohol?(Required)

Never

monthly or less

2-4 times per month

2-3 times per week

4 or more times a week

What is the total number of drinks you have on a typical day when you are drinking?

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

Which of the following best describes your use of cannabis?(Required)

Never

monthly or less

2-4 times per month

2-3 times per week

4 or more times a week

Measurements

Please view this VIDEO for instructions on how to take neck, waist, and hip measurements.

What is your height in feet and inches?(Required)

Use format 5’7″

What is your CURRENT weight in pounds?(Required)

What is the heaviest you have EVER been (pounds)?(Required)

Neck circumference (cm)(Required)

Waist circumference (cm)(Required)

Hip circumference (cm)(Required)

What was your most recently recorded blood pressure?

Format 120/80. If you haven’t had your blood pressure checked recently, please try and do so and let us know. Your primary care physician may have it available if you call them.

How was this blood pressure taken?

Single measurement at doctor’s office

Multiple averaged measurements at doctor’s office

With a home blood pressure cuff

Other

Privacy & Consent

Consent(Required)

I agree to the privacy policy and consent to use of virtual care.

Virtual Care has some inherent privacy and security risks that your health information may be intercepted or unintentionally disclosed. We want to make sure you understand this before we proceed. In order to improve privacy and confidentiality, you should also take steps to participate in Virtual Care in a private setting, use an encrypted email service if available, and you should not use an employer’s or someone else’s computer/device as they may be able to access your information.
If you want more information, please check the Privacy Policy.
If it is determined you require a physical exam you may still need to be assessed in person. You should also understand that virtual care is not a substitute for attending the Emergency Department if urgent care is needed. If you continue, you consent to the use of electronic communication to provide you with care.

Privacy Policy link

Consent(Required)

I understand the CMBH – Lifestyle Medicine Program includes both OHIP-insured and private pay services. I agree to pay for the uninsured services, including health coaching, fitness and nutrition plans.

Payment will be made to our third party service provider for the private pay component of the Program.

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