Download Patient Information

Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
WEIGHT LOSS
HCG TREATMENT
PATIENT
INFORMATION
PACKAGE
1
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
“MEDICAL WEIGHT LOSS OF COOL SPRINGS (MWLOCS) WILL HELP IMPROVE
THE HEALTH OF THE BODY
GOD HAS GIVEN. WE WILL PROVIDE THE KNOWLEDGE,
MEDICATION INSTRUCTIONS , DIET AND EXERCISE INFORMATION TO ASSIST YOU ON
YOUR WEIGHT LOSS JOURNEY . IT IS OUR HOPE THAT AFTER REACHING YOUR
DESIRE WEIGHT LOSS GOAL, YOU WILL CONTINUE TO STRIVE FOR A HEALTHIER
YOU AND MAKE GOOD LIFESTYLE CHOICES .”
CYNTHIA E. COLLINS, MD, CEO OF
MEDICAL WEIGHT LOSS OF COOL SPRINGS .
The Facts about Weight Loss
Being obese can have serious health consequences. These include an increased risk of heart disease,
stroke, high blood pressure, diabetes, gallstones, osteoarthritis, sleep apnea, depression, some forms
of cancer and more. Losing weight can help reduce these risks. Here are some general points to keep
in mind:
Any claims that you can lose weight effortlessly are usually FALSE. The only proven way to lose weight
is either to reduce the number of calories you eat or to increase the number of calories you burn off
through exercise. Most experts recommend a combination of both.
Very low calorie diets are not without risks, and should be pursued only under medical supervision.
Unsupervised very low calorie diets can deprive you of important nutrients and are potentially
dangerous.
Fad diets rarely have any permanent effect. Sudden and radical changes in your eating patterns are
difficult to sustain over time. In addition, so called “crash” diets often send dieters into a cycle of quick
weight loss, followed by a rebound weight gain once normal eating resumes, and makes it even more
difficult to lose weight when the next diet is attempted.
The complications of wt loss are: headaches, dizziness, low blood pressure, low glucose, constipation,
gallstones, kidney stones, and others. MWLOCS will follow the patient closely to avoid unwanted
complications.
To lose weight safely and keep it off requires long-term changes in daily eating and exercise habits.
Many experts recommend a goal of losing about a pound a week. A modest reduction of 500 calories
per day should achieve this goal, since a total reduction of 3,500 calories is required to lose a pound of
fat. An important way to lower caloric intake is to practice healthy eating habits.
Sensible Weight Loss Tips
Losing weight may not be effortless, but it doesn’t have to be complicated. To achieve long-term
results, it is best to avoid quick fix schemes and complex regimens. Focus instead on making modest
changes to your life’s daily routine. A balanced, healthy diet and sensible, regular exercise are the
keys to maintaining your ideal weight.
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Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Although nutrition science is constantly evolving, here are some generally accepted
guidelines for losing and maintaining weight loss.
Here are 13 simple Tips for general Weight Loss:
1. Weight Loss Daily Routine- awaken with bathroom trip, weigh yourself, then take wt loss
treatment. (don’t forget to shout when wt drops)
2. H2O like a Pro- drink plenty of water throughout your day to take the edge off hunger and it
hydrates you. Drink half your weight in ounces daily.
3. Doggie Bag it- when out at a restaurant take half of your serving of food home to lessen your
calories.
4. BYOL- Bring Your Own Lunch to work or school and avoid the fast food invitations.
5. Your Plate- should be ½ cooked foods and ½ uncooked (raw) foods. Don’t go back for seconds,
decrease portions and consider eating on a salad plate. Your plate should look like a rainbow.
6. Pantry Makeover- remove high calorie foods from your pantry, such as high fructose corn syrup
foods. No can goods on wt loss program.
7. Close the Kitchen- turn out the lights after meals, the more you go into the kitchen the more
likely you will be tempted to eat.
8. Burn the Fat- exercise your body 30 minutes per day. Move around in your daily life, park away
from store doors, do active choices (mopping, vacuuming, yard work, etc…).
o Reach your target heart rate while exercising (if medical able).
o 220-your age= Maximum Heart Rate (Max HR)
o Take that # in two ways for your upper and lower limits
o Max HR x 60%= lower range limit and Max HR x 80%= upper range limit
o This is the range for burning fat
9. Power of Sleep- proper sleep 6-8 hours per night is needed for weight loss.
10. Keep a Food Diary- write down what you eat to stay on track.
11. Eat Breakfast- so you don’t overeat later, eat 3 meals a day, and stop eating 3hrs before bedtime.
12. Tackle emotional eating- feeling angry, sad or bored can make you eat so keep health snacks on
hand.
13. Manage stress- help yourself relax by taking 10 minutes for deep breathing while counting your
Blessings! Our God loves Praises!
Avoid or lessen these five items to loss and maintain weight loss:
1. Breads
2.
3.
4.
5.
Sweets
Potatoes
Noodles
Rice
THE HISTORY OF HCG
3
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Human Chorionic Gonadotropin, or HCG, is a natural human hormone produced by the placenta of
pregnant women. One of the purposes of HCG during pregnancy is to ensure tl1e growing baby has a
constant and steady supply of energy and nutrients by mobilizing the reserves stored in the mothers'
adipose (fat) tissue.
The original HCG protocol for weight loss was developed by Dr. A.T.W. Simeons of Salvador Mundi
International Hospital, in Rome, Italy, in the 1950's and 60's. Dr. Simeons realized that regularly limed
small doses of HCG in the average person, men and women who are not pregnant, would have the same
effect, mobilizing approximately 2000 calories worth of stored energy, or 1pound of body fat, making it
available for use by the body. During the 1970's, it was one of the most popular weight loss programs in
the United States, and is now seeing resurgence in popularity.
THE BENEFITS OF HCG
With HCG, your body has a constant and steady supply of energy. This keeps you from feeling hungry,
tired, weak, or irritable. HCG also improves your metabolism. When dieting without HCG, and especially
when eating only a couple of meals per day, your body thinks you are starving, your metabolism slows
down, you become hungry all the time, and your body begins to store any calories it may get because it
does not know when the next meal will come or if it will be big enough to satisfy its nutritional
requirements. In addition, when you are done dieting without HCG, your body stays in that defensive
mode of increased hunger, decreased metabolism, and storing all the calories it can until you have
gained back all the weight you have lost and sometimes more. It does this as a precaution in the event
that you should ever "starve" again, or in other words, go on another diet.
This does not happen with HCG. On the HCG weight loss program of Medical Weight Loss of Cool
Springs, a natural hormone is telling your body to mobilize and utilize its own reserves, filling the
blood stream with a constant supply of energy and nutrients.
This enables you to diet safely and
comfortably lose up to a pound or more every day until you reach a healthy weight.
REAL HCG
We only use the real injectable HCG (PREGNYL) produced by American FDA regulated companies.
Homeopathic drops DO NOT contain real Human Chorionic Gonadotropin. They are mixtures of
supplements which are claimed to mimic the effect of real HCG. However, no supplement, whether it is
a vitamin or herbal remedy, or homeopathic HCG, is required to obtain FDA approval or testing. When
you purchase any supplement, you do so at your own risk and no supplement can truly mimic the effect of
a natural human hormone.
PHASES OF HCG DIET EXPLAINED:
4
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Phase 1 (Gorging, Injections Begin)
refers to the first two days of the diet itself
while starting the intake of HCG. These are the "gorge" days where on e eats on very high fat
foods. Example: avocados, cheeses, heavy cream sauces etc. Two reasons for this phase are noted:
One is to alert the body that extra fat calories need burning, so start those engines. Another is
that this relieves any hunger and other discomfort i n the first week of the diet.
Phase 2 (Diet Begins) starts the intake of the very low caloric diet (VLCD)
of 500
c a l o r i e s and can r u n for 20 to 40 days depending on the amount of weight loss desi red.
The VLCD is specific in the terms of how and what to eat (see sampleh customized diet) and the VLCD
continues for another three days into the maintenance phase.
Phase 3 (Weaning)
is also known as the maintenance phase which runs 3 weeks before
starting another cycle and going back to Phase 1 "gorging". Ad d one week to Phase 3 each time it is
done. It is a continuation of Phase 2, except that the caloric intake is onl y 100 calories more a day
for the first five days after your last injection day. This is important for recalibrating the body's weight
set point. If ones gains 2 pounds above the last Phase 2 weight one should do a "steak day"
involving no breakfast or lunch then eating the l a rgest steak you can find for dinner followed by an
apple.
Phase 4 (New Lifestyle)
is the choices you make for the rest of your life. The majority of
those who have completed the HCG diet as recommended do not regain the weight loss. This may
be due to a combination of a reset metabolism and lifestyle cha nges adopted during the diet.
HIGH IMPACT EXERCISE IS NOT RECOMMENDED DURING THE HCG DIET. LOW IMPACT WALKING ON
TREADMILL, IN MALLS, OR WITH PET IS SUGGESTED.
*Please avoid going to the internet for answers on your diet. The MWL
HCG Diet is customized based on literature review and clinical
experience. If you have any questions please call Medical Weight Loss of
Cool Springs.
5
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Dr. Collins & Vicki Yohe’s
Customized HCG Diet
Day 1 Breakfast:


Coffee, Tea (hot or cold), water
Sweetened with Stevia ONLY or plain
Day 1 Lunch:
 3oz Sirloin steak (159 calories) grilled or baked, see seasonings in Hints list
 10 medium Asparagus spears (30 calories)
 3 cups Lettuce (15 calories) with 2 Tablespoons non-fat Italian dressing (15
calories)- Kroger brand suggested
Day 1 Snack:
 1/2 grapefruit (44 calories)
Day 1 Dinner:
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
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Chicken breast 3.25 oz (suggested Tyson grilled and ready fully cooked- 110
calories)
3 cups Spinach (21 calories)
Standard salad – leafy greens, tomato, and cucumber (30 calories)
Day 1 Snack (2nd):
 2 Grissini breadsticks (40 calories)
 5 medium Strawberries (20 calories)
Dr. Collins & Vicki Yohe’s
Customized HCG Diet
6
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Day 2 Breakfast:


Coffee, Tea (hot or cold), water
Sweetened with Stevia ONLY or plain
Day 2 Lunch:
 Shrimp salad
o 4 cups Lettuce (20 calories) with 2 Tablespoons non-fat Italian dressing
(15 calories)- Kroger brand suggested
 Large Orange (86 calories)
Day 2 Snack:
 2 Melba Toast (24 calories)
Day 2 Dinner:



3oz Sirloin Steak (159 calories)
1 cup of Cabbage (22 calories)
Standard salad (30 calories)
Day 2 Snack (2nd):
 ½ cup raw Blueberries (42calories)
Dr. Collins & Vicki Yohe’s
Customized HCG Diet
7
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Day 3 Breakfast:

 Coffee, Tea (hot or cold), water
Sweetened with Stevia ONLY or plain
Day 3 Lunch:



Chicken breast 3.25 oz (suggested Tyson grilled and ready fully cooked- 110
calories)
3 cups Asparagus (30 calories)
Standard salad (30 calories)
 ½ grapefruit (44 calories)
Day 3 Snack:
 1meduim Apple (95 calories)
Day 3 Dinner:



Tilapia 3oz (96 calories)
3 cups Spinach (21 calories)
Standard salad (30 calories)
Day 3 Snack (2nd):
 Strawberries 10 medium (40 calories)
Dr. Collins & Vicki Yohe’s
8
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Customized HCG Diet
Day 4 Breakfast:

 Coffee, Tea (hot or cold), water
Sweetened with Stevia ONLY or plain
Day 4 Lunch:



Sirloin Steak (159 calories)
Broccoli ½ cup (15 calories)
Standard salad (30 calories)
Day 4 Snack:
 Large Orange (86 calories)
Day 4 Dinner:




Flounder 4oz (100 calories)
1 cup cabbage (22 calories)
1 medium tomato (22 calories)
Standard salad (30 calories)
Day 4 Snack (2nd):
 2 Melba Toast (24 calories)
Dr. Collins & Vicki Yohe’s
Customized HCG Diet
9
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Day 5 – Choose any menu from Day 1-4
(Please review list of approved vegetables, fruits, meats, fish, etc…)
Helpful Hints (Please review):

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Water intake per day should be ½ bodyweight in ounces , ex. 200 pounds would
equal 100 oz of water/day
To help with the sweet tooth you can chew sugar free gum
Standard salad= leafy greens, tomato and cucumber with 2 tablespoons of dressing
Only 2 fruits per day, eating more will decrease wt loss
Only 2 Melba Toast or Grissini breadsticks per day, eating more will decrease wt loss
Meats must be broiled, baked, grilled with no fat added, trim visible fat
Steam, grill, boil, or bake vegetables
Seasonings use the following- lemon juice, pepper, garlic, sweet basil, thyme,
marjoram, cinnamon, small amount of salt (sea salt preferred)
Change meats between lunch and dinner, if possible
Prepare meats in advance for your meals
Remember- palm of hand is size of protein (meats), thumb is tablespoon, and fist is a
cup
A great way to keep track of your calories is to download the MY Fitness Pal app onto
your phone or other wt loss apps.
Join our Facebook page – Medical Weight Loss of Cool Springs for encouragement and
meet other HCG patients.
HCG Food List (ounces):
FRUITS: one fruit per meal, do not mix
10
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Apple- medium (95)
Grapefruit ½- (44)
Orange- large (86)
Strawberries- 10 medium (40)
Blueberries- ½ cup (42)
STARCH:
Melba Toast- 1 (20)
Melba Snack- 2 (24)
Grissini Breadstick- 1 (20)
MEATS: 3 ½ oz, fat removed, weighted raw, cooked in no oil or fat
Chicken Breast-(110)
Ground Beef,95% Lean- (137)
Steak (round/sirloin tip)- (142)
Crab- (84)
Halibut- (110)
Cod- (110)
Flounder- (91)
Tilapia- (96)
Lobster- (90)
Shrimp- (106)
Veal- (112)
VEGETABLES: measured raw, adjust serving size to fit your 500 calories per day
Asparagus- 10 medium spears (30)
Beet-Greens (24)
Cabbage- 1 cup (22)
Celery- 2 cups (32)
Chard- 3 cups (21)
Cucumber- 1 medium (45)
Fennel- 1 cup (27)
Lettuce- 3 cups (15)
Onion- 1/2 cups (32)
Red Radishes- 1 cup sliced(19)
Spinach- 3 cups (21)
Tomatoes- 1 medium (22), 1 cup (27)
Milk- 1 Tablespoon whole milk (9 calories)
HCG Maintenance Phase (3wks): 10 Basic Rules
11
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
1. Increase Calories- increase caloric intake 100 calories per day for 5 days, then
increase or decrease based on weight loss or gain. Estimated max calories per
day is 1000- 1200, but consider Resting Metabolic Rate Testing offered at
MWLOCS for more exact count of daily required caloric intake.
2. Weight Daily- the goal is to stay within 2 pounds of your weight at the time of
the last HCG injection. Gaining or losing more than 2 pounds will reset your
weight clock.
3. No sugar/No Carbohydrates- continue eating the same foods, simply increase
calories.
4. Fats & Dairy- non-processed cheese, sugar- free yogurt can be used
5. Drink Water- ½ your wt in ounces
6. Protein- lean, organic but no pork
7. Steak Day- if your wt goes over 2 pounds from the last injection a steak day is
required- skip breakfast and lunch, then eat the largest steak you can eat for
dinner, followed by an apple. Optional Apple Day- no breakfast then 6 apples
from lunch to lunch and water to drink.
8. Workout- resume regular exercise regiment gradually, 30 minutes 3x week to
5x week
9. No restrictions – on lotions, oils, or beauty products
10.Congratulations!!!!!!!!!!
Enjoy the fabulous new you!
Thanks for making the Medical Weight Loss of Cool Springs your
choice for weight loss management. God has blessed MWLOCS with
an anointing for weight loss. May God Blessings be upon you and we
are praying for your success!!!
www.mwlocs.com
Frequently Asked Questions (FAQ) about HCG Diet:
12
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
What is the history of the HCG diet?



Dr. A.T.W Simeons of Salvador Mundi International Hospital in Rome, Italy
introduced the original HCG diet in the 1950’s and 1960’s.
Dr. Simeons discovered the combination of a restricted calorie diet with the
introduction of small doses of HCG in the average NON-pregnant person would
mobilize approximately 2000 calories of energy or 1 pound of body fat.
During the 1970’s the HCG diet became one of the most popular weight loss
program in the United States.
What is HCG?

HCG or Human Chorionic Gonadotropin is a naturally occurring hormone
produced by the placenta during pregnancy.
How does HCG work?



HCG’s natural functions during pregnancy include protecting the ovaries,
maintaining progesterone levels, increasing immune tolerance, and mobilizing
fat.
During pregnancy, HCG supports the growing baby with energy by mobilizing
nutrients stored in the mother’s adipose (fat) tissue.
HCG biochemically targets fat stores around the hips, thighs, abdomen and
upper arms.
What is the difference between the injections and the drops?



We only use the real injectable HCG (Pregnyl) produced by an American FDA
regulated company.
The homeopathic drops DO NOT contain the real HCG hormone.
The drops are a mixture of supplements that can only mimic the effects of the
real natural human HCG hormone.
Frequently Asked Questions (FAQ) about HCG Diet (cont’d):
13
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
How much weight will I lose?

The average HCG dieter will lose about ½ to 1 pound per day.
Who is eligible for HCG weight loss injections?

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Men and women are both eligible for weight loss with the HCG injection diet.
The same HCG hormone used in the injection is already present in the tissue of
both men and women.
The low dose of HCG used in the diet has virtually no side effects in men or
women.
Pregnant or nursing women are NOT eligible candidates.
Dr. Collin’s will determine an individual’s eligibility for HCG injections.
What are the benefits of HCG injections?
 Average weight loss from ½ to 1 lb per day
 Decreased hunger and Increased Metabolism
 Increased libido in men and women
 No loss of muscle or structural fat
 Decrease in excess fat and stored fat
 Maintaining weight loss despite returning to a regular calorie diet
Is it safe to use HCG injections for weight loss?
 Yes. Although HCG has not been specifically approved by the FDA for weight
loss, it has been FDA approved for the treatment of many other medical
conditions such as infertility.
 The dosages of HCG used for weight loss produces little or no side effects.
Is a very low calorie diet necessary?
 Yes. It is important to create a caloric deficit within the body.
 The HCG hormone will not be induced to mobilize the fat stores and burn them
for energy if there is no decrease of calories coming into the body.
 The typical HCG dieter should limit their caloric intake daily to 500 for the
best wt loss or extend to 700 calories if needed due to symptoms but will not
see the best wt loss.
 Dr. Collins can help guide if a higher daily caloric intake is needed.
Frequently Asked Questions (FAQ) about HCG Diet (cont’d):
14
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Will I be hungry on a 500-700 calorie diet?
 Most HCG dieters report little to no increase in hunger when receiving the
injections.
 HCG has an effect on your hypothalamus gland helping to decrease your food
cravings and reset your metabolism.
What seasonings can be used?
 Salt preferably sea salt(sparingly), pepper, and natural herbs
What are the possible side effects?
 Mild Headache, May increase frequency of migraine headaches
 Constipation due to diet change, but drink the required fluids
 Mild dizziness
 Irregular Menses
 Occasional Bruising
Are there any Adverse Reactions? (RARE)
 Allergic reaction to HCG
 Edema to ankles/feet
 Development of Ovarian Hyper-stimulation Syndrome (OHSS)
Will I plateau?
 There is chance you may plateau around weeks 3 and 4, one possible reason is
constipation. You can use over the treatment to relieve this problem.
 Other reasons for plateau can be discussed with Dr. Collins
What if I went off the diet plan?
 If you went off the plan for a day you can recover by taking a “Steak Day”. Skip
breakfast, lunch and only water to drink, then for dinner eat the largest steak
available and an apple.
 If a steak day doesn’t work, then do an “Apple Day” which consists of no
breakfast then 6 apples from lunch to lunch and water to drink. This can get
your weight loss back on track.
Patient Information:
15
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Name: ________________________________________________________________________________
Age: _________________
Sex:
Date: __________________________
Male / Female
1. Are you in good health at the present time to the best of your knowledge?
Yes
No
(If no, Explain) __________________________________________________________
2. Are you under a doctor’s care at the present time?
Yes
No
(If yes, for what?) ________________________________________________________
3. Are you currently dieting?
Yes
No
(If yes, describe) ________________________________________________________
Medical History:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Prescription Drugs: (List all)
Drug
Dosage
______________________________________________________
______________________________________________________
______________________________________________________
Drug
Dosage
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Over-the-Counter medications, vitamins, supplements: (List all)
Product
Dosage
Product
Dosage
______________________________________________________
___________________________________________________________________
______________________________________________________
___________________________________________________________________
Allergic to any medications?
Medication
_____________________________________________________
_____________________________________________________
_____________________________________________________
Allergic Reaction
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Serious Injuries or Surgeries: (List all)
Date
Injury/Surgery
__________________
_______________________________________________________________________________________________
__________________
_______________________________________________________________________________________________
__________________
_______________________________________________________________________________________________
Women Only:
Date of Last Menstrual Period: _____________________ Age at onset of menstruation: __________________________
Are your periods irregular, painful, or heavy? (If yes, please explain) _______________________________________
____________________________________________________________________________________________________________________________
Number of pregnancies: ____________________________
Number of children: _______________________________
Are you pregnant, trying for pregnancy, or breast feeding?
Yes No
Patient Information (cont’d):
Health History: (check all that apply)
16
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
_____ Dizzy Spells
_____ Convulsions
_____ Kidney Disease
_____ Lung Disease
_____ Rheumatic Fever
_____ Ulcers
_____ Anemia
_____ Tuberculosis
_____ Drug Abuse
_____ Alcohol Abuse
_____ Constipation
_____ Arthritis
_____ Migraines
_____Palpitations
_____High Blood Pressure
_____ Blood Transfusion
_____ Psychiatric Problems
_____ Diarrhea
_____ Eating Disorder
_____ Bleeding Disorder
_____ Nervous Breakdown
_____ Heart Valve Disorder
_____ Gallbladder Disorder
_____ Frequent Headaches
_____ Vascular Disease
_____ Thyroid Disease
_____ Osteoporosis
_____ Moodiness
_____Hyperthyroidism
_____Diabetes
Has any relative ever had any of the following?:
Glaucoma
Y
N
Asthma
Y
N
Epilepsy
Y
N
High Blood Pressure
Y
N
Kidney Disease
Y
N
Diabetes
Y
N
Psychiatric Disorder
Y
N
Heart Disease / Stroke
Y
N
_____ Epilepsy
_____ Pleurisy
_____ Liver Disease
_____ Glaucoma
_____ Gout
_____ Cancer
_____ Heart Disease
_____ Insomnia
_____ Shortness of Breath
_____ Pneumonia
_____Irregular Pulse
_____ Nervousness
_____ Arrhythmia
_____ Hypothyroidism
_____Other:______________
Relation______________________________________
Relation______________________________________
Relation _____________________________________
Relation _____________________________________
Relation _____________________________________
Relation _____________________________________
Relation _____________________________________
Relation _____________________________________
Activity Level: (answer only one)
____
Inactive- no regular physical activity
____
Light Activity- occasionally involved in activities such as walking, weekend golf,
tennis, jogging, swimming or cycling
____
Moderate Activity- consistent lifting, stair climbing, heavy construction, etc., or
regular participation in walking for more than 35 minutes, jogging, swimming, cycling
or active sports at least three times per week
Behavior Style: (answer only one)
____
I am always calm and easygoing.
____
I am usually calm and easygoing.
____
I am sometimes calm and easygoing.
____
I am seldom calm and persistently driving for advancement
____
I am never calm and have overwhelming ambition
____
I am hard-driving and never relax.
Weight History:
Name: ____________________________________________________________________ Date: ____________________________________
17
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
1.
What is the main reason you decided to lose weight? ___________________________________________________
____________________________________________________________________________________________________________________
2.
When did you begin gaining excess weight? ______________________________________________________________
____________________________________________________________________________________________________________________
3.
What do you think is the main cause of your weight problems? _______________________________________
____________________________________________________________________________________________________________________
4.
Describe your previous attempts at weight loss: _________________________________________________________
____________________________________________________________________________________________________________________
5.
Is your spouse/fiancé/partner overweight?
Yes
No
6.
How often do you dine out? Where? What type of food? ________________________________________________
____________________________________________________________________________________________________________________
7.
What is your typical breakfast/lunch/dinner? ___________________________________________________________
____________________________________________________________________________________________________________________
8.
List any food allergies. ________________________________________________________________________________________
____________________________________________________________________________________________________________________
9.
What foods do you crave? ____________________________________________________________________________________
____________________________________________________________________________________________________________________
10. What foods do you avoid? ____________________________________________________________________________________
____________________________________________________________________________________________________________________
11. Do you awaken hungry during the night?
Yes
No
12. What are your worst food habits? __________________________________________________________________________
____________________________________________________________________________________________________________________
Weight History (cont’d):
13. What are your snack habits? ________________________________________________________________________________
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Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
____________________________________________________________________________________________________________________
14. Rate your body from 1 to 10. How would you describe your body?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
15. If you could change one thing about your body, what would it be?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
16. What do you feel will be your main obstacle to successful weight loss?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
17. Rate your salt intake:
High
Medium
Low
18. Rate your fat intake:
High
Medium
Low
19. Rate your caffeine intake:
High
Medium
Low
20. Do you drink alcohol? If yes, what type (wine, beer, liquor)? __________________________________________
How often do you drink alcohol? ___________________________________________________________________________
21. Do you smoke tobacco? Yes
No
How many packs per day? ____________________________________
How long have you smoked? _________________________________________________________________________________
22. Additional information that would be beneficial to the doctor:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
PATIENT INFORMATION
NAME: _______________________________________________________________SSN: _________-_________-_________
19
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
DATE OF BIRTH: ____________________________________SEX: M
F
MARRIED:
Y
N
ADDRESS: _______________________________________________________________________________________________
CITY: ______________________________________________STATE:_______________________ZIP:_________________
HOME (_______) _______________________________________CELL (_______) _________________________________
EMAIL: __________________________________ HOW DID YOU HEAR ABOUT US? __________________________
EMERGENCY CONTACT: ______________________________________ PHONE #: (_____) _____________________
RELATION: ___________________________________________________________________________________________
INSURANCE INFORMATION
Medical insurance policies do not typically cover weight management care and related
services. With the primary diagnosis of Obesity/Overweight, the Medical Weight of Cool
Springs requires payments by cash/credit/debit only. Payments are non-refundable
however credit balances can be transferred to a different weight loss treatment program. An
appropriate receipt of payment will be provided, including charges and descriptions of the
office visit for the different levels of service provided. This can be used for flex accounts or
other insurance services at the patient’s discretion.
Medical Weight Loss of Cool Springs does offer some additional medical weight loss services
that require insurance billing, such as Drug Testing and Resting Metabolic Rate testing that
is performed by consent from the patient.
I have read and fully understand the above information related to insurance and
participation in Medical Weight Loss of Cool Springs weight loss program. Also, I had the
opportunity to ask questions regarding these issues. I am aware that I will receive an
appropriate receipt of payment for my personal use as I see fit to do so. I understand the
specifics of these receipts and limitations as described in this document. I accept these
specific policy rules.
Patient Signature: ____________________________________________________Date: ______________________
Consent for Use or Disclosure of Health Information
Our Privacy Pledge
20
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
We are very concerned with protecting your privacy. While the law requires us to give you this disclosure,
please understand that we have, and always will, respect the privacy of your health information.
There are several circumstances in which we may have to use or disclose your health care information.
 We may have to disclose your health information to another health care provider or a hospital if it is
necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.
 We may have to disclose your health information and billing records to another party if they are
potentially responsible for the payment of your services.
 We may need to use your health information within our practice for quality control or other
operational purposes.
We have a more complete notice that provides a detailed description of how your health information may be
used or disclosed. You have the right to review that notice before you sign this consent form. We reserve the
right to change our privacy practices as described in that notice. If we make a change to our privacy practices,
we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time
for a copy of our privacy notes.
Your right to limit uses or disclosures
You have the right to request that we do not disclose your health information to specific individuals,
companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health
information, please let us know in writing. We are not required to agree to your restrictions. However, if we
agree with your restrictions, the restriction is binding on us.
Your right to revoke your authorization
You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be
able to honor your revocation request if we have already released your health information before we receive
your request to revoke your authorization. If you were required to give your authorization as a condition of
obtaining insurance, the insurance company may have a right to your health information if they decide to
contest any of your claims.
I have read your consent policy and agree to its terms. I am acknowledging that I have received a copy of this
notice.
______________________________________________
Patient Printed Name
________________________________________
Medical Provider Name
______________________________________________
Signature/Date
_________________________________________
Signature/Date
Out of State HCG Program Steps
21
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Medical Weight Loss of Cool Springs has extended our services to help people near
and far. While participating in our Out of State program we assure quality service to
help you during your weight loss journey.
Below are the steps necessary to participate in this program:

Email or fax patient packet with medical form, credit card authorization
form and photo ID.

Dr. Collins will review medical information, if approved; your credit card
will be charged $399.00 plus shipping ($25 regular priority 2- 4 days or
$50 overnight).

You will be called to schedule a Face to Face appointment with Dr. Collins
to go over HCG program. You will be sent a secure medical approved link
for Face to Face videophone visit, via email. You will need to download
and sign into this Videophone system. It works best with iphones, ipads
or desktop computers with a camera. If these devices are not available,
then a regular phone visit will be used temporarily.

HCG WILL BE SHIPPED OUT WITHIN 10 BUISNESS DAYS OR LESS, from the
videophone visit.

Please text or call in your weight once a week and keep a daily log of your
wt on our log sheet given.

For questions or problems
[email protected]
please
contact
Dr.
Collins
Please send weekly weight to 615-974-8826 or via Email to
[email protected]
Authorization for Release of Healthcare Information
22
at
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Patient Identification:
Name: _____________________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________________
City, State, Zip: ____________________________________________________________________________________________________________
DOB: __________________________________________________ SS#: (0ptional)___________________________________________________
I hereby authorize and request the release of my records from:
Physician Name___________________________________________________________________________________________________________
Healthcare Facility: _______________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________________
Phone #: ___________________________________________________________________________________________________________________
Fax #: ______________________________________________________________________________________________________________________
Please send To:
Medical Weight Loss of Cool Springs
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753 office/ 615-771-8757 fax
_____ Recent Office Visit and Labs _______________________________________________________
_____ Recent EKG____________________________________________________________________
_____ Other__________________________________________________________________________
Signature (patient): ______________________________________________________________Date_______________________
(This authorization expires ninety days after it is signed.)
23
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Patient Medical Form (Please complete all):
Name____________________________________________________Date________________________
Age______________________
Date of Birth______________________________________
Weight________________lbs
Height_________ft________inches
BMI___________
(BMI will be calculated by MWLOCS if not available)
BP___________/___________
Pulse____________
Lab Test (required):
Urinanalysis______________________________________________Date______________________
Urine pregnancy test (females)_______
Menopausal ___________yes / no
LMP______________________
Date of onset________________________________
CBC/CMP/Lipids/TSH/Vitamin D (required)
Date_____________________
Labs sent to MWLOCS? Yes / No /Pending____________________________________
Date of last physical ___________________________By__________________________________
Last physical sent to MWLOCS?
Yes / No / Pending________________________
Other___________________________________________________________________________________
__________________________________________________________________________________________
24
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize MEDICAL WEIGHT LOSS OF COOL SPRINGS
To make a onetime debit to your credit card listed below.
By signing this form you give us permission to debit your account for the amount indicated
on or after the indicated date. This is permission for a single transaction only, and does not
provide authorization for any additional unrelated debits or credits to your account.
Please complete the information below:
I ____________________________________________(full name) authorize MEDICAL WEIGHT LOSS
OF COOL SPRINGS to charge my credit card
account indicated for _____________(amount) on or after ___________________(date).
This payment is for _____________________________________ (description of services).
Billing Address ____________________________
Phone# ________________________
City, State, Zip ____________________________
Email ________________________
Account Type:
Visa
MasterCard
AMEX
Discover
Cardholder Name
_________________________________________________
Account Number
_____________________________________________
Expiration Date
_________________________
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) ________________
SIGNATURE
DATE
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined
above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for
one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card
company; so long as the transaction corresponds to the terms indicated in this form.
All information will be secured under our Privacy Agreement!!!
25
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
HOW TO MIX YOUR HCG WITH THE BACTERIOSTATIC
WATER

Step 1: Supplies:
1. One 5ML syringe
2. Only One of your HCG bottle
3. One alcohol wipe
4. One bacteriostatic water

Step 2: Take the caps off your bacteriostatic water and your
HCG. Next, take your alcohol swipe and clean the gray center
of both your HGC and bacteriostatic water.

Step 3: Open your 5ML syringe and take the top off and place it
in the center of your bacteriostatic water. Flip your
bacteriostatic water with the syringe and pull the handle to
the 5ML. Once the syringe is filled up with 5ML of the
bacteriostatic water pull out your bacteriostatic water
bottle out.

Step 4: Place your 5ML syringe into the center of your HCG
bottle.
(Do not mix or shake bottle once your bacteriostatic water is
in.) Once the bacteriostatic water is mixed with the HCG you
have finished with process number 1.
NOTE: Only mix ONE bacteriostatic water with the HCG. Do
NOT use both HCG bottles at once. (They will expire at the
same time if both turned in to liquid the same day)
Once vials are open:
PLEASE KEEP REFRIGERATED
26
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
HOW TO DRAW UP AND INJECT YOUR HCG
 The supplies you need:
1. 5,000 Units of HCG (In liquid)
2. 30 unit insulin syringe
3. 2 alcohol wipes
4. Empty water bottle
 Clean the top center of your HCG liquid with the
first alcohol wipe.
 Next, you will take your second alcohol wipe and
wipe around your subcutaneous layer (One inch from
the belly button). You will uncap your syringe and
inject your HCG from your knuckle from your belly
button. Make sure you pinch the skin and then inject
at a 45 degree angle.
 Take your 30 unit syringe and pull off the white cap
and then uncap the orange cap which is your needle.
 You will then inject the syringe in the center of the
HCG bottle at a 90 degree angle and draw it up all
the way to 25 units.
 Once you have injected your HCG discard the syringe
into an empty water bottle then cap the bottle and
discard.
B-12 Lipoenergetic Wt Management Supplement:
 Take one capsule twice a day
 If given B-12 injections, then one per week into large
muscle (hip or shoulder
27
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
Patient wt/vitals charting (please make additional copies
as needed):
Date
Weight
Wt Loss
Blood
Pressure
Comments:
28
Heart
Rate
Glucose
MWL call
Cynthia E. Collins, MD
100 Covey Drive, Suite 107
Franklin, TN 37067
615-771-8753
www.mwlocs.com
29