PATIENT INFORMATION SHEET (please print) Patient s Name: Birthdate Age. Address: Soc.Sec.# Employer: Address: Phone: Spouse Name: Occupation:
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1 PATIENT INFORMATION SHEET (please print) Today s Date Patient s Name: Birthdate Age First MI Last Address: Soc.Sec.# # and Street City State Zip Telephone # Home:, Work: Occupation: Employer: Address: Phone: Spouse Name: Occupation: Emergency Contact: Phone How did you learn about our office? Have you tried other weight control programs? ************************************************************************************************************* I understand that the start up fee is, and is all inclusive for the first four weeks. Thereafter the biweekly fee is, or a special discounted fee of for four (4) consecutive weeks. There will be an extra charge for above standard dosages of medications. Vitamin B12 (cyanocobalamin) injections are available at a cost of $5. 00 each and $20 for lipotropic B-12 shots. Credit cards, debit cards, check or cash is readily accepted. PLEASE UNDERSTAND THAT THERE IS A $ CHARGE FOR RETURNED CHECKS A large number of studies have proven a much greater rate of successful weight loss among people who come regularly for weigh-ins, medications and counseling. Please do your best to come in regularly. If you are unable to keep a scheduled return appointment, please call the clinic promptly, and we can reschedule you for a different time and/or date. SIGNED
2 Patient Request for Weight Loss Treatment 1. I have been unsuccessful at losing weight or maintaining weight loss by decreasing my food intake and increasing my exercise. I believe my excess weight has had or will have a negative impact on my health and would like to add medical therapy as part of my weight management program. 2. I understand that the risks associated with the use of a prescription appetite suppressant medication in weight reduction and weight management is low when used for three months or less. However, the risks when medications are used for more than three months or in combination have not been studied as comprehensively. therefore, there may be risks associated with the long-term use of appetite suppressants. 3. I understand that I must make a commitment to the lifestyle changes of a low fat, low calorie diet and regular exercise, if permanent weight loss is to occur. I am willing to try to make these lifestyle changes. 4. I understand that if I fail to lose at least 10 pounds or 10% of my initial body weight in the initial three months, or if I share my medication with others, that I may not be a candidate for further medical treatment. 5. I have discussed the above information with the medical staff of Ameri-Cal Weight Clinic and understand that there are alternative therapies available. 6. After reading and understanding the above information, I would like to add medical therapy to a plan of low fat, low calorie diet and regular exercise for weight loss and weight maintenance. Name (print) Signature Witness (print) Signature Physician (print) Signature Date:
3 WEIGHT LOSS PROGRAM INFORMED CONSENT FORM I, authorize Dr. William Brown, M.D. and whomever he designates has his assistants, to help me in my weight reduction efforts. I understand that this program will consist of a balanced deficit diet, a regular exercise program, instruction in behavior modification techniques, and may involve the combined use of the appetite suppressant medications phentermine, phendimetrizine, diethylpropion, sibutramine, and the fat blocking medication orlistat, and the peripheral anticholinergic/antispasmodic/mild sedative Donnatal. The first six medications have been listed by there generic name. Each has one or more brand names and are identified as follows: phentermine: Adipex, Anoxine, Dapex, Fastin, Ionamin, Obe-nix, Obiphen, Parmine, Phentrol, Rolaphent, Unicelles, and Wilpowr. phendimetrazine: Adipost, Anorex, Bacarate, Bontril, Bontril Slow-Release, PDM, Delcozine, Dital, diethylpropion: Tenuate, Tenuate Dospan, Tepanil. I further understand that these appetite suppressants may be used for durations exceeding those recommended in the medication package insert. It has been explained to me that these medications have been used alone and in combination safely and successfully in private medical practices as well as in academic centers for periods exceeding those recommended in product literature. I also understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. Risks of this program may include but are not limited to nervousness, sleeplessness, headaches, dry mouth, gastrointestinal disturbance, weakness, tiredness, psychological problems, high blood pressure, rapid heart beat, and heart irregularities. These and other possible risks could, on occasion, be serious or even fatal. Risks associated with remaining over weight or obese are tendencies to high blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, gall bladder disease, sleep apnea and sudden death. I understand that these risks may be modest if I am not significantly overweight, but will increase with additional weight gain. I understand that much of the success of the program will depend on my efforts and that there is no guarantees or assurances that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require changes in eating habits and permanent changes in behavior to be treated successfully. I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form. If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, as your doctor now before signing this consent form. Date Time Witness Patient
4 HISTORY Today s Date: Name: D.O.B. Age Chief Complaint (reason for seeking help here): Medications being taken & reason: Name of PMD (personal M.D.) Current Medical Problems? (please list) FAMILY HISTORY LIVING DECEASED Age State of health Cause of death Age at death Overweight Father Mother Brothers Sisters Has any immediate family member had: High blood pressure Who? Heart disease Who? Diabetes Who? Asthma Who?
5 SOCIAL HISTORY Smoke? How much Alcohol? How much Height Present weight Highest weight At what age? Desired weight Lowest weight (age 18 - present) At what age? Have you ever been on a special diet or weight loss program? What kind? PAST HISTORY Answer the following questions with yes or no and date or age of onset and current status. Drug Allergies: Yes No To what? Food Allergies: Yes No To what? Surgery: Yes No List, with dates Diabetes Hepatitis/Jaundice Rheumatic fever Low blood sugar HEENT: Headaches or dizziness Fainting Hearing problems Vision problems Glaucoma C-V-R: High blood pressure Heart problems Chest pain Lung problems Shortness of breath Swelling of feet or ankles G-I: Nausea or vomiting Indigestion or heartburn Ulcer Gallbladder problems Constipation Diarrhea Other stomach or colon problems Women: Birth control pills Regular periods Date of last period Last GYN exam Problems? Pregnancies? children? B & J: Arthritis or joint problems Gout N-PSY: Trouble with nerves or depression History of anorexia Bulimia HEM: Anemia Transfusions Endocrinology: Thyroid problems Signature Name (print) Date
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PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE. Date of Appt: / / Name: Date of Birth: / / Last First Middle
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/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
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TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES 13414 Medical Complex Drive, Suite 6 Tomball, TX 77375 281-516-0212 Welcome! We are glad that you have chosen Tomball Regional Internal Medicine Associates
PATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
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Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118
Patient Health History Full Name Date Street Address City & State Zip Phone Number Gender Date of Birth Age SSN How did you hear about our office? Marital Status # of Children? Currently Pregnant? / How
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed