3903 Fair Ridge Drive, Suite 209, Fairfax, VA Harry Byrd Hwy, Suite 285, Ashburn, VA *How did you hear about our program?

Transcription

1 3903 Fair Ridge Drive, Suite 209, Fairfax, VA Harry Byrd Hwy, Suite 285, Ashburn, VA *Hw did yu hear abut ur prgram? Patient Histry Patient Name: First Middle: Last: Address: City: State: Zipcde: Hme Phne: Cell Phne: Birthdate: Age: Sex: M F Address: Emergency Infrmatin Name: Relatinship: Phne: Family Physician Phne: Referred By: Assessing Readiness fr Change On a scale f 1-10, with 10 being 100% ready t take actin, hw ready are yu t lse weight? What is yur attitude twards physical activity? Are yu supprted by family and friends? What are the ptential barriers in yur effrts t lse weight? Thank yu fr yur time and patience in cmpleting these frms. This infrmatin will help us t assist yu better in achieving yur weight lss and wellness gals.

2 Weight Histry Hw lng have yu been trying t lse weight? What is the main reasn behind yur being verweight? What is the main mtivatin fr yur decisin t lse weight? Describe yur activity level: N physical activity (sedentary) Mderate Activity Limited Activity Very Active Have yu ever participated in a structured weight lss prgram? When? Name f prgram: Result: Dietary Behaviral Factrs: D yu prtin cntrl yur sizes? Yes N Frequency f eating: Night-Eating: Binge-Eating: What is yur daily cnsumptin f caffeine (tea, cffee, cla, energy drinks)? Hw many cups per day? D yu drink alchl? Daily Weekly Mnthly Hw much is yur cnsumptin in a sitting? Hw ften d yu watch TV in a day? 1 Hur 2 Hurs 3 Hurs Mre

3 Smking Habits: D nt smke Have quit smking One pack a day Mre than ne pack a day Cigars Other: Medical Histry Are yu in gd health at the present time t the best f yur knwledge? Yes N Are yu taking any medicatins at the present time? Yes N Medicatin Name: Medicatin Name: Medicatin Name: Medicatin Name: Medicatin Name: Medicatin Name: Medicatin Name: Medicatin Name: Reasn: Reasn: Reasn: Reasn: Reasn: Reasn: Reasn: Reasn: Any allergies t any medicatins? Yes N Histry f High Bld Pressure? Yes N Histry f Diabetes? Yes N At what age: Histry f Heart Attack r Chest Pain? Yes N Hustry f Swelling Feet: Yes N Histry f Frequent Headaches: Yes N Migraines? Yes N Medicatins fr Headaches: Yes N Histry f Cnstipatins (difficulty in bwel mvements)? Yes N Histry f Glaucma? Yes N Histry f Epilepsy? Yes N Gyneclgic Histry: Pregnancies: Number: Dates: Natural Delivery r C-Sectin (specify): Last Menstrual Perid:

4 Duratin: Are they regular?: Yes N Pain Assciated? Yes N Cntraceptin Methd: If Menpausal, when was last menstrual perid? Surgical Histry? Please List Specify: Specify: Specify: Date:: Date:: Date:: D yu have a pacemaker? Yes N Family Histry: (if bld relative has suffered the fllwing, please indicate relatinship): Heart Attack Cancer Hypertensin Strke Epilepsy Psychiatric Disrder Arthritis Diabetes Obesity Glaucma Asthma Other Have yu ever been hspitalized? Year: Year: Year: Year: Illness r Operatin:: Illness r Operatin:: Illness r Operatin:: Illness r Operatin:: Past Medical Histry: (Please check all that apply) Glaucma Asthma Tuberculsis Heart Murmur Palpitatins Irregular Pulse Swllen Ankles Chest Pain Eating Disrder Stmach Ulcers Diarrhea Cnstipatin Bldy Stls Gall Bladder Issues Sudden Weight Lss Liver Disrder Jint Pains Fainting Spells Insmnia Depressin Schizphrenia Biplar Disrder Kidney Disrder Headaches Fatigue Anemia Immune Disrders Alchl Abuse Drug Abuse Hypertensin Heart Disease Thyrid Disease Cancer Diabetes Strke Gut Jaundice Arthritis Are yu pregnant? Are yu planning t becme pregnant? Are yu breastfeeding?

5 3903 Fair Ridge Drive, Suite 209, Fairfax, VA Harry Byrd Hwy, Suite 285, Ashburn, VA Infrmed Cnsent fr Prescriptin f Weight Lss Enhancers (A) PROCEDURE AND ALETERNATIVES: 1. I, (patient r patient s guardian) authrizes Nva Physician Wellness Center and its assciates t assist me in my weight reductin effrts. I understand my treatment may invlve, but nt be limited t, the use f weight lss enhancers including prescriptins fr medicatins such as appetite suppressants, synthetic cmpunds, nutritinal supplements, r herbal treatments. I als understand that amin acids, synthetic cmpunds, nutritinal supplements and herbal treatments are ver the cunter nutritinal supplements nt apprved by FDA fr weight lss. I agree that prir t receiving any weight lss enhancers I have met with a Nva Physician Wellness Center healthcare prvider wh has answered any questins I might have abut the ptential benefits and risks f such treatments. 2. I have read and understand the fllwing statements: The healthcare prviders at Nva Physician Wellness Center may prescribe appetite suppressants apprved by the Fd and Drug Administratin r ther weight lss enhancers in dsages higher than thse suggested by the pharmaceutical manufacturer in its package insert r fr perids f time lnger than the twelve (12) week frequently referenced in the insert These patterns f usage are smetimes referred t as ff label usage f the medicatin. Such ff label usage may nt have been as systematically studied in clinical trials as the dses and prescriptin perids described in the package insert. There is a lack f scientific data regarding the ptential danger f lng term use f cmbinatin weight lss treatments. As with mst ther medicatins, there culd be serius side effects (as nted belw) frm all the use f all weight lss enhancers. By signing belw yu agree t accept the risks f side effects f the use f weight lss enhancers as prescribed. Fr female patients, it is imprtant t nte the fllwing regarding sme f the appetite suppressants which may be prescribed. "Given ptential risks t a fetus, it is cntraindicated t be n Phentermine r Qsymia while pregnant r trying t becme pregnant. Fr this reasn, all wmen f childbearing age must be n a reliable frm f cntraceptin. This includes: a) Partner vasectmy b) Oral cntraceptive pills c) Nexplann d) IUD e) Dep Prvera injectin f) Cndm usage 100% f the time g) Tubal ligatin

6 Wmen wh have gne thrugh menpause (12 mnths withut any vaginal bleeding) r have undergne a hysterectmy are cnsidered t have a reliable frm f pregnancy preventin. If while n ne f the afrementined medicatins (Phentermine, Qsymia), yu feel yu may be pregnant, stp the medicatin immediately and call the ffice." 3. It is my respnsibility t fllw carefully the instructins prvided t me by Nva Physician Wellness Center including returning t the Center fr all fllw-up appintments. I will reprt any medical prblems that I think may be related t my weight cntrl prgram as sn as reasnably pssible, t the healthcare prvider treating me fr my weight lss. 4. The purpse f this treatment is t assist me in my desire t decrease my bdy weight and t maintaining this weight lss. I understand that cntinuing the prescriptin f the appetite suppressant will be dependent n my cmpliance with the Center s ttal weight lss prgram. Dietary interventin and physical exercise are part f any weight lss regimen. I acknwledge that these and ther ways r prgrams might assist me in my desire t decrease my bdy weight and t maintain this weight lss. In particular, a balanced calrie cunting prgram r an exchange eating prgram withut the use f the appetite suppressant wuld likely prve successful if fllwed, even thugh I wuld prbably be hungrier withut the appetite suppressants. I have reviewed the Infrmed Cnsent fr Weight Lss. (B) RISKS OF PROPOSED TREATMENTS: I acknwledge the use f the appetite suppressants r ther weight lss enhancers invlves ptential risks and hazards. The mre cmmn side effects frm the use f appetite suppressants include: nervusness, sleeplessness, headaches, dry muth, weakness, tiredness, psychlgical prblems, medicatin allergies, high bld pressure, rapid heartbeat and heart irregularities. Less cmmn, but mre serius, risks are primary pulmnary hypertensin and valvular heart disease. These and ther pssible risks culd be serius r fatal. (C) RISKS ASSOCIATED WITH BEING OVERWEIGHT OR OBESE: I am aware that there are certain risks assciated with remaining verweight r bese. Amng thse are tendencies f high bld pressure, diabetes, heart attack and heart disease, and arthritis f the jints, hips, knees and feet. I understand these risks may be mdest if I am nt very much verweight, but that these risks can g up significantly the mre verweight I am. (D) NO GUARENTEES: I acknwledge that much f the success f the prgram will depend n my effrts and that there are n guarantees r assurances that the prgram will be successful. I als understand that I will have t cntinue watching my weight all f my life if I am t be successful. (E) PATIENT S CONSENT: I have read and fully understd this cnsent frm and I realize I shuld nt sign this frm if all items have nt been explained, r any questins I have cncerning them have nt been answered t my cmplete satisfactin. I have been urged t take all the time I need in reading and understanding this frm and in talking with my healthcare prviders regarding risks assciated with the prpsed treatment and regarding ther treatments nt invlving the appetite suppressants. WARNING: If yu have any questins as t the risks r hazards f the prpsed treatment, r any questins whatsever cncerning the prpsed treatment r ther pssible treatments, ask yur healthcare prvider NOW BEFORE SIGNING THIS

7 CONSENT FORM. By signing this frm, I acknwledge the receipt f the infrmatin cntained herein, my understanding f the risks and benefits f the weight lss prgram, my willingness t cmply with the prgram s requirements, and my cnsent t the use f appetite suppressants and ther weight lss enhancers assciated with the weight lss prgram prescribed by Nva Physician Wellness Center. PRINT NAME: DATE: PATIENT SIGNATURE:

8 3903 Fair Ridge Drive, Suite 209, Fairfax, VA Harry Byrd Hwy, Suite 285, Ashburn, VA Infrmed Cnsent fr Weight Lss WARNING: Rapid weight lss may cause serius health prblems. Rapid weight lss is weight lss f mre than 1 1/2 punds t 2 punds per week r weight lss f mre than 1 percent f bdy weight per week after the secnd week f participatin in a weight lss prgram. Cnsult yur persnal physician befre starting any weight lss prgram. Only permanent lifestyle changes, such as making healthful fd chices and increasing physical activity, prmte lng-term weight lss. Qualificatins f this prvider are available upn request. Yu have a right t: ask questins abut the ptential health risks f this prgram and its nutritinal cntent, psychlgical supprt, and educatinal cmpnents; receive an itemized statement f the actual r estimated price f the weight lss prgram, including extra prducts, services, supplements, examinatins, and labratry tests; knw the actual r estimated duratin f the prgram; knw the name, address and qualificatins f the dietitian r nutritinist wh has reviewed and apprved the weight lss prgram. I have read the abve: PRINT NAME: DATE: PATIENT SIGNATURE: