Welcome to our Center! We are so glad you have chosen our center to assist you with your weight loss goals!

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1 Welcome to our Center! We are so glad you have chosen our center to assist you with your weight loss goals! What to expect.. Your first appointment with our center will last approximately one hour, possibly more. During your first appointment you will meet with the nurse practitioner and a medical assistant to review this patient packet and discuss your medical weight loss options. The nurse practitioner will determine the need for lab work based on your history and physical exam. Please come fasting for lab work. If you have had lab work done within the last 3 months please have it faxed to our office beforehand (fax: ) Directions to our center.. The Center for Surgical and Medical Weight Loss is located at 2021 Church Street, Suite 104 Nashville, Tennessee If you are traveling on I-65 Northbound or I-24 Westbound: 1) Follow signs to I-40 West. 2) Exit at Church Street/Charlotte Pike - exit 209 3) Take LEFT onto Church Street once you exit off the ramp 4) Turn LEFT onto 21 st Avenue (one way street) 5) When you come to the stop sign, take a LEFT onto Hayes Street 6) On your left, there will be a Parking Garage; take a LEFT into the first entrance of the parking garage 7) SEE directions below for Parking Garage Directions If you are traveling on I-40 Eastbound: 1) Exit at Charlotte Pike - exit 209 2) Turn RIGHT at the bottom of the exit ramp onto Charlotte Pike 3) Turn LEFT onto 21 st Avenue (one way street); cross over Church Street at the traffic light 4) When you come to the stop sign, take a LEFT onto Hayes Street 5) On your left, there will be a Parking Garage; take a left into the first entrance of the parking garage 6) SEE directions below for Parking Garage Directions Parking Garage Directions: Parking, which is free for both patients and visitors, is located primarily on Hayes Street. When you enter the parking garage, choose a space that is most convenient. Take the elevator or the stairs to Level L. Once you exit the stairs or the elevator, you will see 2 glass doors that enter into the main lobby of the Medical Plaza. Enter through those doors. Our office is straight ahead, past Elite Physical Therapy. We are in Suite 104. *Please make a note to help you remember where you parked!

2 *This box for Office Use ONLY* Patient Demographics Primary Insurance: Secondary Insurance: Today s Date: Name: First MI Last Date of Birth: SS#: - - Mailing Address: City, State & Zip: Home Phone: Work Phone: Cell Phone: Best time to reach you during the day: Where should we call? Is it ok to leave a message on your voic ? Yes/No E Mail Address: Is it OK to reach you by E MAIL: Yes/ No Preferred Language: Need Interpreter: Yes/No Employer: Emergency Contact: Relationship: Phone: Name of Primary Care Physician: PCP Office Phone #: PCP Practice Name: PCP Fax #: Were you referred to us? Yes/No Who referred you to our office? Preferred Pharmacy Name: Pharmacy Phone #:

3 Medical Weight Loss Assessment Form Patient Name: Date of Birth: Age: Sex: Marital Status: Single Married Domestic Partnership Divorced Widowed Allergies: Past Medical History: (Please check yes or no for each condition.) Medical Condition YES NO Medical Condition YES NO Cancer Migraines High Blood Pressure Seizures Heart Disease Depression High Cholesterol Glaucoma Diabetes Thyroid disorder Sleep Apnea Kidney Stones Arthritis Polycystic ovary syndrome Acid Reflux Kidney Disease Stroke Liver disease Substance Abuse Eating disorder Heart Murmur Review of Systems: Put a check if you experience any of the following symptoms: Symptom YES NO Symptom YES NO Fever Joint Pain Blurry Vision/Vision Changes Back Pain Sinus problems/congestion Numbness Chest pain Seizures Chest pain with exertion Dizziness Shortness of breath Headache Palpitations/Heart Racing Confusion Abdominal pain Abnormal Periods Nausea Insomnia Vomiting Suicidal Thoughts Diarrhea Nervousness Constipation Fatigue Increased appetite Heat/Cold intolerance Date of Last Menstrual Period: post-menopausal hysterectomy Are you currently sexually active? YES or NO Do you use contraception (birth control)? If so, circle all forms of birth control used: Condoms Oral birth control pills Tubul Ligation Nuvaring IUD Natural Family Planning Implanon/Nexplanon Male partner s vasectomy

4 Patient Name: Date of Birth: Current Medications: (Please list all current medications, vitamins, and minerals OR attach a complete list) Name of medication Dosage Name of medication Dosage Family History: (Please check yes or no for each condition.) Medical Condition YES NO Cancer High Blood Pressure Heart Disease High Cholesterol Diabetes Sleep Apnea Obesity Stroke Sudden death <40 years old Is your father living? YES NO If no, cause and date of death: Is your mother living? YES NO If no, cause and date of death: Surgical History Type of Surgery Laparoscopic or Open Procedure? Year Social History Occupation: Status (circle one): Full time/part time/ Retired/ Disabled Do you have children? YES NO If yes, how many? Do you use tobacco products? YES NO Do you consume alcohol? YES NO If yes how many drinks per week? Do you have any religious or cultural concerns that we should be aware of? YES NO If yes, please explain:

5 Patient Name: Date of Birth: Personal Weight & Nutrition History: What has been your highest weight? What is the most weight you have ever lost? (Please check any programs that you have attempted.) Exercise programs Prescription medications Over the counter medications Weight Watchers Jenny Craig Optifast Nutrisystem Atkins None Others: Which diet were you most successful with? List 3 reasons why you think it is important you lose weight (in order of importance) #1 #2 #3 How many meals do you typically eat out per week? Are the majority of theses meals with family or friends? Are these meals usually fast food? Are you presently undergoing any major life changes (marriage, divorce, death of a family member, etc.)? What social challenges do you face that present an obstacle to you and your weight loss goals (occupational related eating, travel, household issues, financial issues, schedule, etc.)? Who do you feel will be supportive of your weigh loss and lifestyle changes? Please circle all that apply. Spouse Significant other Children Coworkers Parents Friends Other Have you ever been severely depressed? Have you ever had suicidal thoughts?

6 Patient Name: Date of Birth: Do any of the following help explain or describe your eating habits? Check all that apply. Thinking about food too much Uncontrollable binges Eating too quickly Eating in reaction to being sad Overeating at social events Eating in reaction boredom Overeating alone Using food as a reward Eating too many high fat foods Not paying attention to what I m eating Eating too many sweets Eating to take my mind off problems Eating too many carbs Do you have any known food allergies (soy, cocoa, shellfish, gluten, eggs etc.)? Do you have any known food sensitivities (artificial sweetener, lactose, MSG etc.)? Exercise History: How many days per week do you exercise? What kind of exercise or physical activity do you do? Are there any barriers in your life that prevent you from exercising more (joint problems, risk of falls, fatigue, time or money constraints, etc.)? FOR STAFF ONLY (complete or attach Tanita slip) Height: Weight: BMI: Blood Pressure: Heart Rate: