| RPT |
.|.|MOVE!23||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.>
buy food 'to go' ?| <*Answer_4074*>|16. How much regular soda, sweet tea, juice, or juicy drinks do you drink most days? (Do not include diet or sugar free soda, unsweetened tea, or other sugar
free drinks.)| <*Answer_4075*>|17. How many alcoholic drinks do you have in an average week? (One serving is a 12 oz can of beer or malt liquor or a 6 oz glasses of wine or a 1 oz shot of
hard/distilled liquor.)| <*Answer_4076*>|18. How fast do you usually eat?| <*Answer_4077*>|19. On average, how often have you eaten extremely large amounts of food and felt that your eating was
out of control at that time?| <*Answer_4078*>|20. Do you use a wheelchair or are largely confined to your bed?| <*Answer_4079*>|21a. Are you limited in any daily activities or work performance
because of your physical health? Climbing a flight of stairs:| <*Answer_4080*>|21b. Are you limited in any daily activities or work performance because of your physical health? Walking several
blocks:| <*Answer_4081*>|21c. Are you limited in any daily activities or work performance because of your physical health? Lifting or carrying packages or groceries:| <*Answer_4082*>|22. Using
the 1-10 scale below, which number best describes your typical daily physical activity/exercise? "1" indicates no activity, "5" indicates 15 minutes every three days, "10" means one hour or more of
daily exercise/activity. | <*Answer_4083*>|23. Which statement most closely applies to your attitude about exercise?| <*Answer_4084*>|24. Which statement best indicates how much you agree with,
"I am satisfied with my current level of fitness."| <*Answer_4085*>|| $~
(<.Patient_Age.>)|Gender: <.Patient_Gender.>||Questions and Answers||1. Please check any of the following medical conditions or health problems you currently have:| <*Answer_4056*>|2. I consider
myself to be:| <*Answer_4057*>|3. Select the answer that best describes your rate of weight gain over the years:| <*Answer_4058*>|4. Select the answer that best describes your family:|
<*Answer_4059*>|5. Which statement most closely applies to you:| <*Answer_4060*>|6. How much weight do you think you realistically could lose in one year without surgery?| <*Answer_4061*>|7.
How confident are you that you can lose weight and keep it off?| <*Answer_4062*>|8. How satisfied are you with the appearance of your body?| <*Answer_4063*>|9. Do any of the following have
anything to do with your being overweight? Check all that apply to you.| <*Answer_4064*>|10. How much can you rely on family or friends for support and encouragement?| <*Answer_4068*>|11. What
do you think may get in the way of changing your eating habits? Check all that apply to you.| <*Answer_4069*>|12. What do you think may get in the way of changing your physical activity habits?
Check all that apply to you.| <*Answer_4070*>|13. Are you currently experiencing any of the following? Check all that apply.| <*Answer_4071*>|13a. Are you currently being treated for any of
the following? Check all that apply.| <*Answer_4072*>|14. How many times a day do you typically eat, including snacks?| <*Answer_4073*>|15. How many times a week do you usually eat 'out' or
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