Physicians Weight Clinic, Inc.

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Acquaintance Sheet Date: Name: Date of Birth: Sex: M F Age: Address: City, State & Zip: Home Phone: Cell: Work: Please put a check mark next to the phone # that would be best to reach you or leave a message. Email: Referred By: Occupation: Employed By: How did you hear about us?

Important Treatment Information Please read and Initial each numbered item below 1. I understand to only take the prescribed dosage of oral medication that I am given and I will not give the medication to another person. 2. I will notify this office of ANY and ALL changes of prescribed and over the counter medications I am taking, including strength and dose. 3. I will update this office whenever I have a new diagnosis or new medical issue I am being treated for by all other medical offices I receive care from. This includes psychiatric or emotional disorders as well as any new medications when prescribed elsewhere. 4. I understand I will receive my weight management participation medical examination at Physicians Weight Clinic, Inc. for the sole purpose of the weight management program. All medical staff s directives and treatments should not be regarded as care from a primary care physician. 5. I understand all injections have inherent risk which may include, but not be limited to, bruising, bleeding, infection, injection site reaction and allergic reaction. 6. Federal regulations require packaging of medication in child resistant containers if children are present to prevent accidental ingestion. PRINT Name: I have read, understood, agreed to and initialed all the items above. Patient s Signature: Date

Possible Program Contraindications Please circle your answers to these questions, and then sign below: Are you pregnant, breastfeeding or planning to get pregnant soon? (Appetite suppressant medication should not be taken while pregnant, breastfeeding or attempting to conceive as the risks to the fetus and fertility are unknown, but potentially serious or life threatening. Serious adverse reactions can occur in nursing infants.) Are you currently on: Prozac, Paxil, Zoloft, Celexa, Effexor, Wellbutrin, Elavil, Cymbalta,Trazodone, Buspirone (Buspar), St. John s Wort, or any other type of anti-depressant? Are you currently on any medication for migraines such as; Axert, Amerge, Imitrex, Imigran, or Zomig? Are you currently on Nardil, Parnate, Marplan, or Emsam (MAOI) Have untreated or uncontrolled high blood pressure? History of any heart problem: e.g. By-pass surgery, stent, valve problem? Other Heart disease: Pacemaker, defibrillator, arrhythmia, WPW? History of a Stroke - Cerebrovascular accident (CVA)? History of peripheral arterial/vascular disease (PAD/PVD)? Advanced kidney or liver disease? History of Thyroid disease? Have ever or currently undergoing drug addiction treatment? Are you allergic, or ever had a bad reaction to stimulant drugs? If you answer YES to any of the ABOVE please inform the office Before scheduling your initial appointment. Thank You! Print your name above Patient s signature Date

Medical History Questionnaire This medical history and physical exam are for our purposes at Physicians Weight Clinic and in no way replace your care and exams with your health care provider. NAME: DOB: AGE: HT: Please list ALL drug ALLERGIES, including prescription, herbal and over-the-counter medications: Please list ALL medications and dosage you are taking, including prescription, herbal and over-the-counter medications: Please list ALL diet medications you have used: Do you have ANY history of? Heart disease/problems (of any kind) Y or N Alcoholism or Drug Abuse Y or N Irregular Heart beat/palpitations/chest pain Y or N Shortness of breath (without exertion) Y or N Heart murmur or mitral valve prolapse Y or N High Cholesterol Y or N High Blood Pressure Y or N Stroke Y or N Depression, Anxiety, or Panic Disorder Y or N Headaches or Migraines Y or N Anorexia, Bulimia, or other eating disorder Y or N Glaucoma Y or N Sensitivity to Stimulant drugs Y or N Thyroid Problems Y or N Diabetes: I, II or Gestational Y or N Positive TB test/treatment for TB Y or N Seizures or epilepsy Y or N Liver disease, hepatitis, jaundice Y or N Lung disease: COPD, asthma, emphysema Y or N Gallstones Y or N Peripheral Arterial Disease Y or N Scarlet Fever or rheumatic fever Y or N Blood disease: Anemia, blood clots, sickle cell, bleeding problems Y or N Digestive Problems: IBS, chronic constipation, diarrhea, acid reflux, diverticulitis, ulcers Y or N Are you Pregnant or Breastfeeding? Y or N Date of last menstrual period/menopause: What is your current birth control method? Do you have any Family History of: heart disease, high blood pressure, stroke, or diabetes? If yes, please list who and at what age they were diagnosed. Is there any ADDITIONAL INFORMATION regarding your medical history you would like us to know? I declare to the best of my knowledge this information is complete and true. I agree Physicians Weight Clinic providers believing it to be TRUE, shall rely and act upon it in making medical decisions about my weight loss treatment. Patient s signature: Date: Physicians Weight Clinic reviewer signature: Date:

HIPAA Notice of Privacy Practices How your HEALTH INFORMATION may be used: TO PROVIDE TREATMENT We will use your Health Information within our office to provide you with the best health care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between physician assistant, nurse practitioner, nurse physician and business office staff. In addition, we may share your health information with referring physicians, clinical and pathology laboratories, pharmacies or other health care personnel providing you treatment. TO CONDUCT HEALTH CARE OPERATIONS Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in the training progress for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities. PATIENT REMINDERS Because we believe regular care is very important to your general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best care modern medicine can provide. They may include letters, telephone reminders, or voice mails regarding labs or future appointments. Please be sure the receptionist has your current contact information to insure accuracy and your privacy. FOR LAW ENFORCEMENT As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION Other than is stated above or where Federal, State of Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time. I have read and understand the above information. Signature: Date:

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