In Balance. Female Focused Weight Loss. DunneWithDieting.com. Thank you for your interest in our medically supervised weight loss program.

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1 In Balance Female Focused Weight Loss DunneWithDieting.com Dear Patient, Thank you for your interest in our medically supervised weight loss program. Please fill out the following intake form and return it to the office before you schedule your first visit Fax (914) attn: Dawn This intake form has two purposes 1. Identify codes we can submit to your insurance company Insurance companies do not generally cover weight loss per se However, they will cover the co-morbidities associated with excess weight If your BMI is greater than 30, they should cover unless you have an obesity exclusion They may also cover if your BMI is greater than 27 with more than one co-morbidity 2. Identify issues you have been struggling with in your efforts to lose and maintain a healthy weight and lifestyle This information will provide the supporting documentation that your insurance company requires to cover these services After we receive your completed forms, we will provide you with the ICD and CPT codes that you can use to contact your insurance company to check coverage. These visits are billed as problem visits (as they are not considered preventative) and may be subject to a co-pay or deductible. These visits do NOT require pre-authorization. We simply suggest you check with your insurance ahead of time regarding possible out-of-pocket expenses. To schedule or reschedule any of these appointments, please contact Dawn directly. Otherwise your appointment may not be scheduled correctly and may need to be rescheduled. Please be courteous of our scheduling procedures. If you are unable to keep your appointment please contact the office within 24 hours to cancel. We understand that things come up but please take the time to reach out to us. This will allow sufficient time for another patient to schedule their appointment. After two no-show appointments, we will no longer be able to take to care of you.

2 Date Name Date of Birth Age In Balance Female Focused Weight Loss DunneWithDieting.com Julianne Dunne, MD Lisa Luehman, NP Height Current Weight Goal Weight What is the main reason you want to lose weight? Readiness to Change Importance of change. How important is it for you to change your diet and lifestyle habits to lose weight? (low importance) (high importance) Readiness to change. How ready are you to change your diet and lifestyle habits to lose weight? (low importance) (high importance) Confidence in your ability to change. How confident are you in your ability to change? (low importance) (high importance) Check all the medical issues that apply to you: high blood pressure stroke insulin resistance sleep apnea autoimmune disorder high cholesterol fatty liver disease diabetes asthma depression high triglycerides gastric reflux thyroid disorder osteoarthritis anxiety heart disease eating disorder PCOS gout cancer Do you currently take any medication on a regular basis? Include over-the-counter medications, vitamins and herbal remedies Drug name Dosage How often? Purpose Are you allergic to any medications? no known drug allergies seasonal allergies Drug name rash or hives swelling of lip or tongue anaphylaxis rash or hives swelling of lip or tongue anaphylaxis rash or hives swelling of lip or tongue anaphylaxis List past surgeries or hospitalizations. Year Surgical procedure or reason for hospitalization Year Surgical procedure or reason for hospitalization

3 Family History. Check all that apply Was your mother overweight at your conception? Was your father overweight at your conception? during your childhood? during your childhood? mother high blood pressure high cholesterol diabetes stroke Alzheimer s cancer father high blood pressure high cholesterol diabetes stroke Alzheimer s cancer sisters high blood pressure high cholesterol diabetes stroke Alzheimer s cancer brothers high blood pressure high cholesterol diabetes stroke Alzheimer s cancer aunts/uncles high blood pressure high cholesterol diabetes stroke Alzheimer s cancer grandparents high blood pressure high cholesterol diabetes stroke Alzheimer s cancer cousins high blood pressure high cholesterol diabetes stroke Alzheimer s cancer Gynecologic History When was the 1st day of your last period? If you are in your reproductive years, are your periods regular? My periods are light moderate heavy heavy with clots Do you experience premenstrual symptoms? If yes, do the symptoms interfere with your day to day activities? If in menopause, what year was your last period? Are you having? hot flashes irritability vaginal dryness painful intercourse difficulty sleeping Are you currently sexually active? If yes, are you currently planning pregnancy? If you are not planning pregnancy, which of the following methods are you using? none condoms pills/nuvaring depo-provera Nexplanon Mirena/Skyla/Kyleena/Paragard vasectomy tubal ligation/essure Obstetric History How many times have you been pregnant? How many live births? If you have children, were they delivered by vaginal birth cesarean delivery both Social History Marital status: single married widowed divorced separated Who lives at home with you? What is your occupation? Describe: desk job stand on feet often heavy lifting Describe your commute to work: drive take public transportation walk to work bike to work Do you smoke cigarettes? never former smoker current smoker e-cigarettes If a former/current smoker, how many packs? <1 pack per day (ppd) 1 ppd 1-2 ppd >2 ppd Do you drink alcohol? 0-12 drinks/year 1-13 drinks/month 4-14 drinks/week >2 drinks/day If yes, beer wine liquor (on the rocks or with club soda) cocktails (liquor with juice or tonic) Have you ever been treated for alcohol abuse? Do you have family history of alcohol abuse? Do you use recreational drugs? If yes, please list Have you ever been treated for drug abuse? Do you have family history of drug abuse?

4 Diet History 1. Which of the following commercial weight loss programs have you tried? none Pounds lost Length of participation Why it worked/why it didn t work Weight Watchers Nutrisystem Jenny Craig Liquid diet Overeaters anonymous 2. Which of the following weight loss medications have you tried? none Pounds lost Length of participation Why it worked/why it didn t work phentermine/qsymia Belviq Contrave Saxenda Orlistat 3. Which of the following popular diets have you tried? none Pounds lost Length of participation Why it worked/why it didn t work Atkins/ketogenic Mediterranean Paleo Vegan/vegetarian other 4. Do you eat for the following reasons? Self-reward no sometimes yes Stressed no sometimes yes Angry no sometimes yes Depressed no sometimes yes Nervous or worried no sometimes yes Lonely no sometimes yes Food Triggers 1. What triggers you to overeat? Check all that may apply stress boredom comfort eating foods 2. When you eat foods, can you easily stop? 3. Are you compelled to eat until all the food is gone? 4. If you have foods in your immediate environment, do you feel you must eat them? 5. Are you easily full? 6. Do you feel less panicky or feel relief after eating? 7. Do you have difficulty resisting temptations?

5 Eating Pattern Questionnaire 1. Do you follow a special diet? no low fat low sodium Kosher vegetarian diabetic gluten-free other 2. Which meals do you regularly eat? Check all that may apply o breakfast lunch brunch dinner snacks 3. When do you usually snack? Check all that may apply o morning afternoon evening late night throughout the day never 4. How often do you eat out? o never 1-2x/week 3-5x/week 6-7x/week daily 5. Do you eat fast food? o 6. How is your food usually prepared? Check all that may apply baked broiled boiled fried steamed poached other 7. Do you binge eat (large amounts of food in a short period of time)? o no sometimes often 8. Do you eat after 7pm? 9. How many times each day do you have the following food items? a. Starch (bread, bagel, roll, cereal, noodles, rice, potato) never less than b. Fruit never less than c. Vegetables never less than d. Dairy (milk, yogurt) never less than e. Protein (meat, fish, poultry, eggs, cheese) never less than f. Fat (butter, margarine, mayonnaise, oil, salad dressing) never less than What beverages do you drink daily and how much? water times or glasses per day (8 oz) coffee tea soda alcohol other times or glasses per day times or glasses per day times or glasses per day (12 oz) times or glasses per day times or glasses per day 11. What do you think is your biggest challenge to losing weight? Check all that may apply Portion control Snacking when bored Emotional or stress snacking Not feeling full after a healthy portion Not eating the right foods due to personal food preferences or lack of time

6 Physical Activity Do you exercise regularly now? If yes, Which activities? How many times per week? For how long? If no, what keeps you from exercising? Check all that may apply No time Too expensive Gym/classes are too intimidating Physical impairment Don t like to sweat Inactivity How many hours a day do you spend watching TV, Netflix, etc.? or longer How many hours a day do you spend sitting at a desk or at a computer? or longer Physical Activity Readiness Questionnaire 1. Has your doctor ever said that you have a heart condition and they you should only do physical activity recommended by a doctor 2. Do you feel pain in your chest when you do physical activity? 3. In the past month, have you had chest pain when you were not doing physical activity? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? 5. Do you a bone or joint problem that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? 7. Do you know of any other reason why you should not do physical activity?

7 Hormone Balance Questionnaire Read carefully through the list of symptoms. Fill in circle () next to any you experience. Note each part should be answered separately. Some answers may be repeated. Do you or have you experienced any of the following symptoms in the past 6 months CORTISOL EXCESS A feeling you are constantly racing from one task to the next? Feeling wired yet tired? A struggle calming down before bedtime, or a second wind that keeps you up late? Difficulty falling asleep or disrupted sleep? A feeling of anxiety or nervousness can t stop worrying about things beyond your control? A quickness to feel anger or rage frequent screaming or yelling? Memory lapses or feeling distracted, especially under duress? Sugar cravings (you need a little something after each meal, usually chocolate!)? Increased abdominal circumference, greater than 35 inches (abdominal fat, or muffin top)? Skin conditions such as eczema or thin skin? Bone loss (medical terms such as osteopenia or osteoporosis)? High blood pressure or rapid heartbeat? High blood sugar (diabetes, pre-diabetes or insulin resistance)? Indigestion, ulcers, or GERD (reflux)? More difficulty recovering from physical injury than in the past? Unexplained pink to purple stretch marks on your belly or back? Irregular menstrual cycles? Decreased fertility? CORTISOL DEFICIENCY Fatigue or burnout (you use caffeine to bolster your energy or fall asleep while watching TV)? Loss of stamina, particularly from 2 to 5 in the afternoon? An atypical addiction to a negative point of view? Crying spurts for no particular reason? Decreased problem-solving ability? Feeling stressed most of the time (everything seems harder than before, or trouble coping?) Insomnia or difficulty staying asleep, especially between one and four in the morning? Low blood pressure (not always a good thing)? Difficulty fighting infection or difficulty recovering from illness, surgery, or wound healing? Asthma? Bronchitis? Chronic cough? Allergies? Low or unstable blood sugar? Salt cravings? Excess sweating? Nausea, vomiting, or diarrhea? Or loose stool alternating with constipation? Muscle weakness, especially around the knees? Muscle or joint pain? Hemorrhoids or varicose veins? Your blood seems to pool easily or your skin bruises easily? You felt better with treated thyroid problem, but suddenly you feel palpitations or irregular heartbeats?

8 ESTROGEN DEFICIENCY Poor memory (you walk into a room to do something, then forget what it was)?! Emotional fragility, especially compared with how you felt ten years ago)? Depression, perhaps with anxiety or lethargy? Wrinkles (your favorite skin cream no longer works miracles)? Night sweats or hot flashes? Trouble sleeping, waking up in the middle of the night? A leaky or overactive bladder? Bladder infections? Droopy breasts, or breasts lessening in volume? Sun damage more obvious, even glaring on your chest, face, and shoulders? Achy joints (you feel positively geriatric at times? Recent injuries, particularly to wrists, shoulders, lower back, or knees? Loss of interest in exercise? Bone loss? Vaginal dryness, irritation, or loss of feeling? Lack of juiciness everywhere (dry eyes, dry skin, dry clitoris)? Low libido (it s been dwindling for a while)? Painful sex? ESTROGEN EXCESS Bloating, puffiness, or water retention? Abnormal Pap smears? Heavy bleeding? Rapid weight gain, particularly in the hips and butt? Increased bra-cup size or breast tenderness? Uterine fibroids? Endometriosis or painful periods? Mood swings, PMS, depression, or just irritability? Weepiness, sometimes over the most ridiculous things? Mini breakdowns or anxiety? Migraines or other headaches? Insomnia? Brain fog? A red flush on your face (or a diagnosis of rosacea)? Gallbladder problems or removal? PROGESTERONE DEFICIENCY Agitation or PMS? Cyclic headaches (particularly menstrual or hormonal headaches)? Irregular menstrual cycles, or cycles becoming more frequent as you age? Heavy or painful periods (heavy: soaking a pad every 2 hours; pain: can t function without ibuprofen)? Bloating, particularly in the ankles and belly? Fluid retention? Easily disrupted sleep? Itchy or restless legs, especially at night? Increased clumsiness or poor coordination?

9 ANDROGEN EXCESS Excess hair on your face, chest, or arms? Acne? Greasy skin and/or hair? Thinning hair on your head? Discoloration of your armpits (darker and thicker than your normal skin)? Skin tags, especially on your neck and upper torso? Hyperglycemia (high blood sugar), hypoglycemia (low blood sugar) or unstable blood sugar? Reactivity and/or irritability, or excessively aggressive or authoritarian episodes? Depression? Anxiety? Menstrual cycles occurring more than every 35 days? Ovarian cysts? Midcycle pain? Infertility? Or subfertility (no pregnancy < 12 months of trying)? Polycystic ovarian syndrome? THYROID IMBALANCE Hair loss, including the outer third of your eyebrows and/or eyelashes? Dry skin, dry straw-like hair that easily tangles, or thin, brittle fingernails? Fluid retention or swollen ankles? An additional few pounds, or 20, that you just can t lose? High cholesterol? Bowel movements less often than once a day, or you feel you don t completely evacuate? Recurrent headaches? Decreased sweating? Muscle or joint aches or poor muscle tone? Tingling in your hands or feet? Cold hands and feet? Cold intolerance? Heat intolerance? A sensitivity to cold (you are always wearing layers or you shiver more easily than others)? Slow speech, slow thoughts or difficulty concentrating? A slow heart rate, bradycardia (< 60 beats per minute but not because you are an elite athlete)? Lethargy (you feel like you are moving through molasses)? Fatigue, particularly in the morning? Sluggish reflexes, diminished reaction time, even a bit of apathy? Low sex drive, and you re not sure why? Depression or moodiness? A prescription for the latest antidepressant but you re still not feeling like yourself? Heavy periods or other menstrual problems? History of infertility, miscarriage, or pre-term birth? An enlarged thyroid/goiter, difficulty swallowing or enlarged tongue? A family history of thyroid problems?

10 Diet Readiness Questionnaire For each question, select the best answer that describes how you feel. Goals and Attitudes 1. Compared to other attempts, how you motivated to lose weight are you at this time? o Not at all motivated o Slightly motivated motivated o Quite motivated o Extremely motivated 2. How are you that you will be committed to a weight loss program for the time it will take to reach your goal? o Not at all o Slightly o Quite o Extremely 3. Consider all outside factors at this time in your life (the stress your are feeling at work, your family obligations, etc). To what extent can you tolerate the effort required to stick to a diet? o Cannot tolerate o Can somewhat tolerate o Un o Can tolerate well o Can tolerate easily 4. Think honestly about how much weight you hope to lose and how quickly you hope to lose it. Figuring a weight loss of 1 to 2 pounds per week, how realistic is your expectation? o Very unrealistic unrealistic o Moderately unrealistic realistic o Very realistic 5. While dieting, do you think about eating a lot of your favorite foods? o Always o Frequently o Occasionally o Rarely o Never 6. While dieting, do you feel deprived, angry and/or upset? o Always o Frequently o Occasionally o Rarely o Never Hunger and Eating Cues 7. When food comes up on conversation or in something your read, do you want to eat even if you are not hungry? o Never o Rarely o Occasionally o Frequently o Always 8. How often do you eat because of physical hunger? o Always o Frequently o Occasionally o Rarely o Never 9. If your favorite foods are around the house, do you have trouble controlling urges? o Never o Rarely o Occasionally o Frequently o Always

11 Controlled Eating If the following situations occurred while you were on a diet, would you be likely to eat more or less immediately afterward and for the rest of the day? 10. Although you planned on skipping lunch, a friend talks you into going out for a midday meal much less somewhat less o Would make no difference somewhat more much more 11. You break your diet by eating a fattening, forbidden food much less somewhat less o Would make no difference somewhat more much more 12. You have been following your diet faithfully and decide to test yourself by eating something you consider a treat much less somewhat less o Would make no difference somewhat more much more Binge Eating and Purging 13. Aside from holidays, have your ever eaten a large amount of food rapidly and felt that you are eating was out of control? o Yes o No 14. If you answered yes to #13 above, how often have you engaged in this behavior during the last year? o Less than a month o About once a month o A few times a month o About once a week o About three times a week o Daily 15. Have you ever purged (used laxatives, diuretics or induced vomiting) to control your weight? o Yes o No 16. If you answered yes to #15 above, how often have you engaged in this behavior during the last year? o Less than a month o About once a month o A few times a month o About once a week o About three times a week o Daily

12 Emotional Eating 17. Do you eat more than you would like to when you have negative feelings such as anxiety, depression, anger or loneliness? o Never o Rarely o Occasionally o Frequently o Always 18. When you have interpersonal stress, or after a difficult day at work, do you eat more than you d like? o Never o Rarely o Occasionally o Frequently o Always 19. When you have difficult interpersonal stress, or after a day at work, do you eat more than you d like? o Never o Rarely o Occasionally o Frequently o Always Exercise Patterns and Attitudes 20. How often do you exercise? o Never o Rarely o Occasionally o Frequently o Always 21. How confident are you that you can exercise regularly? o Not at all confident o Slightly confident confident o Highly confident o Completely confident 22. When you think about exercise, do you develop a positive or negative picture in your mind? o Completely negative negative o Neutral positive o Completely positive 23. How are you can work regular exercise into your daily schedule? o Not at all o Slightly ly o Quite o Extremely Support and Confidence 24. How supportive are your family and friends with your weight loss goals? o Very supportive and encouraging o Moderately supportive o Indifferent o Not supportive or encouraging 25. How confident and optimistic are you in your ability to lose weight through this medically supervised weight management program? o I am sure I am going to reach my goal weight o I think I will come close to reaching my goal weight o I don t think I will lose weight

13 Sleep History How many hours of sleep do you get per night? How well do you sleep at night? though the night fall asleep easily but can t stay asleep difficulty falling asleep frequent or early morning wakening Sleep Apnea Assessment Do you snore extremely loud so that you may be heard from another room? Do you often feel tired, fatigued or sleepy during the daytime? Has anyone ever observed that you pause in your breathing when you sleep? Are you treated for high blood pressure? Is your Body Mass Index (BMI) > 35? Are you age 50 or older? Is your neck circumference greater than 16 inches? Are you male? Total unsure unsure Have you ever had a sleep study? What were the results? If you have been diagnosed with sleep apnea, do you use a CPAP machine? The Epworth Sleepiness Scale Use the scale below to choose the most appropriate number for each situation 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing SITUATION Sitting and reading Watching TV Sitting inactive in a public place (e.g. in a theater) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic CHANCE OF DOZING

14 Patient Health Questionnaire (PHQ 9) Are you currently being treated for depression? Are you currently being treated for anxiety? Are you taking medication for depression or anxiety? If yes, which ones? Do you have family history of depression or anxiety? Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you re a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself TOTAL If you checked off any problems, how difficult have these problems made if for you to do your work, take care of things at home, or get along with other people? o Not difficult at all difficult o Very difficult o Extremely difficult

15 Review of Symptoms Do you have any of the following general symptoms? fatigue difficulty sleeping snoring daytime sleepiness forgetfulness Do you have any of the following visual symptoms? blurry vision double vision loss of vision Do you have any of the following ear, nose or throat symptoms? sore throat hoarseness nasal/sinus problems Do you have any of the following cardiovascular symptoms? chest pain palpitations leg swelling sudden awakening from sleep with shortness of breath passing out varicose veins hemorrhoids Do you have any of the following pulmonary symptoms? shortness of breath wheezing blood in sputum sleep apnea Do you have any of the following gastrointestinal symptoms? gastric reflux/heartburn gallstones constipation vomiting diarrhea abdominal pain blood in stool Do you have any of the following urinary symptoms? loss of urine frequent urination prolapsed bladder or uterus blood in urine Do you have any of the following musculoskeletal symptoms? low back pain knee pain joint pain/swelling muscle pain/cramps muscle stiffness Do you have any of the following skin conditions? acne eczema dark skin around neck or groin stretch marks skin tags skin ulcers Do you have any of the following neurologic symptoms? frequent headache weakness carpal tunnel syndrome impaired balance numbness or tingling Do you have any of the following psychological symptoms? depression stress anxiety poor self-image social isolation Do you have any of the following endocrine symptoms? heat intolerance cold intolerance increased thirst excessive sweating Do you have any of the following allergic symptoms? hives hay fever food allergies or sensitivities frequent infections Do you have any of the following gynecologic symptoms? irregular periods painful periods genital itch or discharge premenstrual syndrome low sex drive Do you have any of the following reproductive issues? infertility recurrent miscarriage pregnancy complications