Download Weight Loss Intake Form - MD Medical Weight Loss and Wellness

Medical Weight Loss and Wellness Center
PATIENT DEMOGRAPHICS
Please Print
Name: ______________________________________________________________________________________________________
First
Middle
Last
Address: ____________________________________________________________________________________________________
City: _________________________________________________State: _________________________Zip:______________________
Home Phone: (____) ____________________________________Cell: (____) _____________________________________________
E-Mail: ______________________________________________________________________________________________________
Date of Birth: _________________________Social Security #:______________________________Sex: Male or Female
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Marital Status (Circle One)
Single
Race:__________________________Language Spoken:________________________
Married
Widowed
Divorced
Employer: _____________________________________________Work Phone: (___) ______________________________________
Physician Info.
Referring Physician: _________________________________Phone: (___) _______________________________________________
Family MD: ________________________________________Phone: (___) _______________________________________________
Emergency Contact Outside Of Home
Name: ________________________________ Phone: (___) _______________________ Relationship: ________________________
How did you hear about our practice? __________________________________________________________
Personal Weight History:
Height
Current Weight _______________Goal Weight ________________________________________________
Birth Weight: ________________
Weight one year ago: _________________
Are you in good health at the present time to the best of your knowledge?
Yes
No
Explain a 'No' ______________________________________________________________________________________________
_________________________________________________________________________________________________________
What is your three main reason for your decision to lose weight? _____________________________________________________
How committed are you for this program and improving your health? Are you willing to make lifestyle changes that are needed for
program to be successful? ___________________________________________________________________________________
When did you begin gaining excess weight? (Give reasons, if known): ________________________________________________
What has been your maximum lifetime weight (non-pregnant) and when? ______________________________________________
How much weight do you expect to lose with MD Medical Weight Loss and Wellness Centers? ____________________________
In what time frame would you like to be at your desired weight? _____________________________________________________
What weight loss programs have you tried? ______________________________________________________________________
________________________________________________________________________________________________________
Which method of weight loss do you consider most successful for yourself? ____________________________________________
Why did you stop? __________________________________________________________________________________________
What was the main obstacle to weight maintenance? _______________________________________________________________
Medical History:
Previous Medical Conditions
Abnormal Periods
Asthma
Diabetes: type 1 type 2
Eating Disorder
Glaucoma
Heart Disease
High Blood Pressure
High Cholesterol
Sleep Apnea
Insomnia
Kidney Disease
Polycystic Ovarian Syndrome
Thyroid Disease
Alcohol Abuse
COPD
Gall Stones
Kidney Stones
Back Pain
Previous head bleed
Stroke
Seizure Disorders
Depression/Mental Health
Are you undergoing any major lifestyle changes? __________________________________________________________________
Gynecologic History:
Yes
No
Are you pregnant now?
Are you planning to get pregnant?
Are you breast feeding now?
Any other Hospitalizations, surgeries or major illness (Please specify date and why and where?): _____________________________
____________________________________________________________________________________________________________
Current Medications including Over the Counter Medications:
Medications
Medications
Drug Allergies: ____________________________________________________________________________________________
__________________________________________________________________________________________________________
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Are you taking any SSRIs (selective serotonin reuptake inhibitors)? Ex— Prozac, etc.
Are you taking any MAOIs (Monoamine oxidase inhibitors)?
Are you taking any medications for Glaucoma?
Have you ever had an episode of Acute Angle Closure Glaucoma?
Yes
Yes
Yes
Yes
No
No
No
No
Family Medical History:
Disease
Cancer
Diabetes
Stroke
Sudden Death < 40 years old
Heart Disease
Family History of weight: Are your family members Overweight?
High Cholesterol
Yes or
Obesity
No
Social History:
Smoke/ Tobacco Use:
Alcohol Use:
Drug Use:
Living situation:
Employed
Yes
Yes
Yes
Married
Yes
No
No
No
Partner
Alone
No
Who do you feel will be supportive of your weight loss and lifestyle changes? Please circle all that apply.
spouse
children
roomate
coworkers’
parent’s
friends
other
Functional Ability:
House Work
Yes
No
Employment
Yes
No
Yard Work
Yes
No
Grocery Shopping
Yes
No
Extended Standing
Yes
No
Extended Sitting
Yes
No
Lifestyle and Eating Habits:
How many meals do you typically eat out per week? _______________________________________________________________
Are the majority of these meals with family or friends? _____________________________________________________________
Are these meals usually fast food? ______________________________________________________________________________
Of the following, check all that you feel help explain or describe your eating habits:
Thinking about food too much
Eating in reaction to tension/depression
Using food as a reward
Eating in reaction to boredom
Not paying attention to what I’m eating
Eating high fat foods
Eating too many sweet foods
Uncontrollable binges
Eating too quickly
Overeating at social events
Lack of satisfaction in life
Overeating when alone
Eating to take mind off problems
Continuing to eat even though you are full
Are you allergic to any foods or sweeteners? _______________________________________________________________________
Sleep:
What time do you go to bed? _________________________________________________________________________
What time do you fall asleep? ________________________________________________________________________
How many hours do you sleep? _______________________________________________________________________
Do you snore? _____________________________________________________________________________________
Do you feel refreshed after waking up? _________________________________________________________________
How is your energy level during the day? _______________________________________________________________
Lifestyle and Eating Habits, cont.:
Foods you dislike? ___________________________________________________________________________________________
Foods you crave? ____________________________________________________________________________________________
At what time of the day do you crave for food? _____________________________________________________________________
How often do you cook at home in a week? ________________________________________________________________________
How often does the whole family eat together? _____________________________________________________________________
How often do you eat on ‘go’? __________________________________________________________________________________
How often do you eat fast food? _________________________________________________________________________________
Do you 'Graze'? ______________________________________________________________________________________________
Typical Breakfast
Typical Lunch
What do you eat?
Where and with whom do you eat?
Are you interested in any other services we provide? If so, what part of the body?
Body contouring -Skin tightening -Cellulite treatment -Wrinkle reduction --
Typical Dinner
HIPAA PRIVACY AUTHORIZATION FORM
Authorization for use or disclosure of protected health information.
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. parts 160 and 164)
1. Authorization
I authorize MIDWEST WELLNESS LLC (healthcare provider) to use and disclose the protected health information.
2. Effective Period
This authorization for release of information covers the period of healthcare from:
a. All present, past and future
3. Extent of Authorization
a. I authorize the release of my complete health record (Including records relating to mental healthcare,
communicable diseases, HIV or AIDS and treatment for alcohol or drug abuse).
b. I authorize the release of my complete health record with the exception of the following:
- Mental Health Records
- Communicable Diseases (including HIV and AIDS)
- Alcohol/Drug abuse treatment
- Other (please specify): __________________________________________________________________
4. This information may be used by the person I authorize to receive this information for medical treatment or
consultation, billing or claims payment or other purposes as I may direct.
5. This authorization shall be enforced and effect until __________________________ (date or event), at which
time this authorization expires.
6. I understand the right to revoke this authorization, in writing, at any time. I understand that a revocation is not
effective to the extent that any person or entity has already acted in reliance on my authorization or if my
authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to
contest a claim.
7. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on
whether I sign this authorization.
8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient
and may no longer be protected by federal or state law.
9. I understand that when requesting a family member or friend be in the exam room with me when my health is
being discussed, the physician is not violating my HIPAA rights. Initial________
____________________________________________
Signature of patient or personal representative
____________________________________________
Printed name of above signed
____________________________________________
Date
CONDITIONS OF SERVICE
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I authorize the release of any and all medical records, including but not limited to Radiology, Laboratory,
and other ancillary services’ results, as well as Histories, Physicals, Correspondence and Medication
information contained or held by any referring, primary, pharmacy or emergency facility.
I allow fax or electronic transmission of applicable records if necessary.
I understand payment is due at time of service unless other definitive and contracted financial
arrangements have been agreed upon.
I agree to pay all reasonable attorney fees/collection cost in the event of default of payment charges.
I am in agreement with Medical Weight Loss and Wellness Center payment schedules and office policies.
I am responsible for any unpaid balances/deductibles on any Medical Weight Loss and Wellness Center
accounts.
I am giving Medical Weight Loss and Wellness Center permission to treat my medical condition.
I certify that the information provided on these documents is true and correct to the best of my knowledge.
I have read and fully understand the above Consent for Treatment, Financial Responsibility and Release of
Information Authorization.
I understand that if drug use is suspected, testing will be required.
I give Medical Weight Loss and Wellness Center permission to leave a message at:
o _____Any phone number listed
o _____Only the following phone number _____________________________________________
regarding appointment information/instructions, test results, or financial information.
_____ I do not give Medical Weight Loss and Wellness Center permission to leave a message at any of the
phone numbers I have listed.
_____ I do or _____ I do not give Medical Weight Loss and Wellness Center permission to speak to the
following family members regarding my medical condition (if they inquire).
o Names:________________________________________________________________________
o Relations:______________________________________________________________________
o Phone #:_______________________________________________________________________
o ______Any/All Family members
Refill Policy: We can refill any Medications over the phone except for Controlled Substances. We can refill
Prescriptions one time after not being seen, but any more refills, we prefer to see you.
_______________________________________________________
Patient’s Signature
__________________
Date
Statement of Patient Financial Responsibility
Patient Name _______________________________DOB__________________________
MD Medical Weight Loss and Wellness Center appreciates the confidence you have shown in
choosing us to provide your healthcare needs. The service you have elected to participate in
implies a financial responsilibity on your part. The responsibility obligaes you to ensure payment
in full of our fees. Payment is required at the time services are rendered. We accept payments
in the form of cash, check, credit cards, HAS cards and FSA cards.
I have read the above policy regarding my financial resonsibility to MD Medical Weight Loss and
Wellness Center for providing services to me or the above named patient. I certify that the
information is to the best of my knowledge, true, and accurate.
Patient Signature__________________________________Date__________________________
Guarantor Signature________________________________Date_________________________
(If guarantor is not the patient)
Cancellation / No Show Policy
24 hours cancellation notice is required if you are unable to keep your appointment. All no
show Appointments will be charged a $25.00 fee due prior to the next appointment. I have
read and understand the above information, and agree to the terms described:
Patient/Guarantor Signature____________________________Date______________________
Insurance Reimbursement
Please note that MD Medical Weight Loss and Wellness Center does not file insurance claims.
We will provide a superbill for your insurance filing needs.
Patient/Guarantor Signature____________________________Date______________________
Weight Loss Program Consent Form
I ______________________________________ authorize Midwest Wellness LLC and Dr. _Kesa and whomever they designate as
their assistants, to help me in my weight reduction efforts. I understand that my program may consist of a balanced deficit diet, a
regular exercise program, instruction in behavior modification techniques, and may involve the use of appetite suppressant
medications. Other treatment options may include a very low calorie diet, or a protein supplemented diet. I further understand that
if appetite suppressants are used, they 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 safely and successfully in private medical practices as well as in
academic centers for periods exceeding those recommended in the product literature.
I 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 disturbances, weakness, tiredness, psychological problems, high blood pressure,
rapid heartbeat, and heart irregularities. These and other possible risks could, on occasion, be serious or even fatal. Risks associated
with remaining overweight are tendencies to high blood pressure, diabetes, heart attack and heart disease, arthritis of the joints
including hips, knees, feet and back, 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 success of the program will depend on my efforts and that there are 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, ask your doctor now before signing this consent form.
Date:
Time:
Witness:
Patient:
(Or person with authority to consent for patient)
PATIENT RIGHT AND RESPONSIBILITIES
As a patient of Medical Weight Loss and Wellness Center, you have the right to:
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Receive services without regard to age, race, color, sexual orientation, religion, marital status, sex or national origin.
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Be treated with consideration, respect and dignity including privacy in treatment.
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Be free from abuse or neglect as well as the fear of being abused or neglected.
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Be informed of the services available at the Center and of the provision for emergency coverage after business hours.
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Be informed of the charges for services and eligibility for third-party reimbursements.
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Obtain from your healthcare practitioner, or the healthcare practitioner’s delegate, complete and current information concerning your
diagnosis, treatment and prognosis in terms you can be reasonably expected to understand.
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Receive from your physician information necessary to give informed consent prior to the start of any non-emergency procedure or
treatment or both. An informed consent will include as a minimum, the provision of information concerning the specific procedure or
treatment or both, the reasonable foreseeable risks involved and alternatives for care or treatment, if any, as a reasonable medical
practitioner under similar circumstances would disclose in a manner permitting the patient to make a knowledgeable decision.
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Refusal to participate in experimental research.
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Refusal of any medical care or treatment as well as being provided information regarding medical outcomes of such refusal.
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Voice grievances and recommend changes in policies and services to the Center’s staff, administration, owner, the Indiana State
Department of Health or the Office of the Medicare Beneficiary Ombudsman, without fear of reprisal.
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Privacy and confidentiality of all information and records pertaining to your care and treatment.
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Approve or refuse the release or disclosure of the contents of your medical record to any healthcare practitioner and/or healthcare
facility except for those providing and/or following your care at the Center or as required by law or third-party payment contracts, as is
consistent with the Center’s HIPPA policy.
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Access to your medical record.
Concerns/Problems/Complaints regarding your healthcare:
If you have a concern, problem, or complaint related to any aspect of the provision of your care at this Center, speak to your doctor, nurse other
staff member or Center administration so that we may address and correct your concerns immediately. If facility staff then fails to resolve the
problem, you may file a complaint with the Indiana State Department of Health by calling the toll-free number 1-800-246-8909. Written
complaints should be addressed to:
Indiana State Department of Health
Division of Long Term Care
2 North Meridian Street, 4B
Indianapolis, IN 46204
Complaints or grievances may also be filed with the Office of the Medicare Beneficiary Ombudsman by visiting their website at:
www.medicare.gov/Ombudsman/resources.asp
As a patient of Medical Weight Loss and Wellness Center, you have the responsibility for:
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Providing, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, medications and
other pertinent facts relating to health status. You are also responsible for making it known whether you clearly understand your
treatment and care and what is expected of you for that care.
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Following the treatment plan recommended by your healthcare practitioner including but not limited to the instructions of nurses and
other healthcare personnel at the Center.
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Keeping appointments and when unable to do so, notify the Center by telephone.
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Actions and outcomes, which may occur to you, should you refuse treatment or fail to follow instructions.
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Asking questions about your bill, if applicable, providing necessary information to assist your insurance company to pay your bill and
fulfilling all financial obligations for your healthcare as promptly as possible.
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Being considerate to the rights of other patients and Center personnel and being respectful of the property of others and the facility.
Ownership Disclosure: Srinivasu Kesa, is sole owner of Medical Weight Loss and Wellness Center.