Download Medical Weight Management Patients

The Lester Clinic of Integrative Medicine
&
California Medical Weight Management
Welcome!
Dear Patient,
We would like to welcome you to The Lester Clinic of Integrative Medicine & California Medical Weight
Management. Our three-step, medically-supervised weight management program offers an exceptional
weight loss protocol without adverse side effects. During your time on the program, you will be guided,
educated and monitored every step of the way. Our clinical staff is here to assist you and will meet with
you regularly during the healthy-weight attainment process, as well as our Physician and Physician
Assistant (P.A.). Your health and individual medical needs will be assessed and monitored throughout.
Step One is the rapid weight loss part of the program. In your initial clinic visit, our medical staff will take
a complete medical history, along with a physical exam specific for weight loss,a complete body
composition with our state-of-the-art equipment, an EKG and blood work, all of which are required to
determine eligibility for the program.
After the initial consultation and orientation, you will be monitored on a weekly basis by our medical
staff to ensure your weight loss goal is reached safely and swiftly. A combination of vitamins, minerals
and other supplements assures the preservation of your good health while you reach your ideal weight.
Depending on your individual needs, an FDA-approved appetite suppressant medication may be
prescribed and implemented into your custom-designed protocol. Medications and therapeutic
injections are dispensed at our clinic for your convenience and are included in the weekly charges.
Additional supplements and vitamins may be purchased separately, as needed.
Step Two, will begin when you have reached your body-weight / body-fat goal. We help you to
integrate the changes into your lifestyle in a way that preserves your new and improved health status.
Office visits at this point are important for you to shift into an established maintenance level, and not
revert back to your previous body-composition. We are retraining your body’s metabolism and will
monitor your continued progress at this point toward that goal.
Step Three is a comprehensive long-term ideal-weight maintenance program, with emphases on
behavioral modification, nutrition, and exercise programs – all aiming at stabilizing your newly-attained
state and building greater health and well-being for the rest of your life, through knowledge and
application.
To your health,
~ Dr. Lester
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Dr. Jeff Lester, D.O. – The Lester Clinic of Integrative Medicine
65 Aspen Way, Watsonville, CA 95076 ~ 831-724-1164 ~ [email protected]
3700 Thomas Rd. #207, Santa Clara, CA 95054 ~ 408-844-0010 ~ [email protected]
www.lesterclinic.com (general clinic) ~ www.calmwm.com (weight management)
New Patient Registration Packet
This packet is provided to help you prepare for your upcoming visits with us. In order for us to serve
you better and lessen your wait time before your 1st appointment, please complete the enclosed
forms and bring them with you at the time of your appointment, or email or fax them in ahead of time.
Inside this packet you will find:
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Patient Registration Form
Patient Medical History and Questionnaire
Weight History
Consent for Medical Weight Loss Treatment
Notice of Privacy Practices
Please remember to bring:
Your current medications that you are taking
This Registration Packet
If you are a new patient of Dr. Lester:
Please plan to spend approximately 1-hour for your initial appointment. This time may vary according
to tests that are being performed. After that, the follow-up appointment will be briefer, approximately
15 minutes.
Financial responsibility:
You are responsible for all payments at the end of your office-visit. The payment is non-refundable
and non-transferable at any time during the program. If your insurance covers this treatment, you are
welcome to submit the statements yourself and be reimbursed directly, but we are not able to bill them
from our offices at this time. Payments to our office can be made by credit card, check or cash, and
we utilize a third-party-financing company as need be (www.carecredit.com).
If you have any questions, please do not hesitate to call and speak with one of our friendly and helpful
staff members by calling us at the number below, specific to the clinic you plan to attend.
We look forward to assisting you!
~ The Staff at California Medical Weight Management
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Dr. Jeff Lester, D.O. – The Lester Clinic of Integrative Medicine
65 Aspen Way, Watsonville, CA 95076 ~ 831-724-1164 ~ [email protected]
3700 Thomas Rd. #207, Santa Clara, CA 95054 ~ 408-844-0010 ~ [email protected]
www.lesterclinic.com (general clinic) ~ www.calmwm.com (weight management)
PERSONAL REGISTRATION FORM
Date:
____________
Patient Name: First___________________________Last
Address: ___________________________
____
City________
State:______Zip
____
Phone: Home (____)______-________ Work (____)______-________ Cell (____)______-________
E-mail: ________________________________Alternate E-mail:
Age:
Date of Birth: ___________________
Sex: M
____ ____
F Marital Status:
____
Occupation:
____
Employer: _______________________________________________________________
____
Address:
____
Phone: (______) _____________________________
Extension #:
____
Emergency Contact Info:
Name_
Relationship to Patient ____ ______ Phone
____
Primary Care Physician: _____________________________________________________________
Address:
____
Phone: (______) _____________________________ Fax: (______)
____
How did you find us:
______ Present patient of Dr. Lester
______ Physician Referral (name:
______ Internet Search
______ Family/Friend (name:
______ Phone Book
______ Advertisement (where:
______ Newspaper
______ Flyer (where:
______ TV
______ Radio
)
)
)
)
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Dr. Jeff Lester, D.O. – The Lester Clinic of Integrative Medicine
65 Aspen Way, Watsonville, CA 95076 ~ 831-724-1164 ~ [email protected]
3700 Thomas Rd. #207, Santa Clara, CA 95054 ~ 408-844-0010 ~ [email protected]
www.lesterclinic.com (general clinic) ~ www.calmwm.com (weight management)
Patient Name: First: _________________________ Last:
------------------------------------------------------------------------------------------------------------------------------------------
PERSONAL HABITS
Do you drink alcohol? Yes___No___ If yes, what & how much?
Do you smoke? Yes___No____ If yes, how much & how long?
If you previously used tobacco, when did you quit?
Do you use recreational drugs? Yes___No___ If so, what kind & how much?
WEIGHT HISTORY
Your current weight:
_____ What do you think is your ideal weight?
Your weight 1 year ago:
5 years ago:
What is/was your maximum weight:
10 years ago:
At what age?
What was your lowest weight as an adult:
Age:
Did you consider yourself obese as a teenager? Yes
Have you tried to lose weight in the past? Yes
What Methods? Diets Plans
Which Diet Program:
No
No
Food Plans
How long:
Programs
How much did you lose?
Do you know why you regained weight? Yes___No___
Type and Frequency of Current Physical Activity:
Is your Wife/Husband/Partner overweight?
Is any of your immediate family overweight? If yes please list:
Is your weight having an impact on your relationship? Yes
No
How often do you eat at restaurants and what type of food do you order?
Do you have any food allergies that you’re aware of? Yes
No
If so, to what, and what happens:
Have you been medically tested for this, and if so when & where:
------------------------------------------------------------------------------------------------------------------------------
Dr. Jeff Lester, D.O. – The Lester Clinic of Integrative Medicine
65 Aspen Way, Watsonville, CA 95076 ~ 831-724-1164 ~ [email protected]
3700 Thomas Rd. #207, Santa Clara, CA 95054 ~ 408-844-0010 ~ [email protected]
www.lesterclinic.com (general clinic) ~ www.calmwm.com (weight management)
Patient Name: First: _________________________ Last:
------------------------------------------------------------------------------------------------------------------------------------------
HABITS & GOALS
Tell us about your breakfast? Time? Place?
Tell us about your lunch? Time? Place?
Tell us about your dinner? Time? Place?
What are your worst food habits?
What foods do you avoid?
What foods do you crave?
Do you snack during the day?
How would you illustrate your body?
What would you change about your body?
What does your ideal body look like?
Comments to help us with your treatment:
PERSONAL HISTORY
Do you have any history of the following conditions or symptoms?
Hypertension
Yes___No___
High Cholesterol
Yes___No___
Heart Disease
Yes___No___
Cyst of Breast or Ovary
Yes___No___
Thyroid Disease
Yes___No___
Substance Abuse
Yes___No___
Psychiatric Illness
Yes___No___
If yes to any of the above, please describe:
Diabetes
High Lipids
Glaucoma
Seizures
Alcoholism
Migraine
Sleep Apnea
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Other:
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Dr. Jeff Lester, D.O. – The Lester Clinic of Integrative Medicine
65 Aspen Way, Watsonville, CA 95076 ~ 831-724-1164 ~ [email protected]
3700 Thomas Rd. #207, Santa Clara, CA 95054 ~ 408-844-0010 ~ [email protected]
www.lesterclinic.com (general clinic) ~ www.calmwm.com (weight management)
Patient Name: First: _________________________ Last:
-----------------------------------------------------------------------------------------------------------------------------------------Do you have a family history of any of the following conditions?
Hypertension
High Cholesterol
Heart Disease
Cyst of Breast or Ovary
Thyroid Disease
Substance Abuse
Psychiatric Illness
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Diabetes
High Lipid
Glaucoma
Seizure
Alcoholism
Migraine
Other
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Yes___No___
Are you currently pregnant? Yes
No
_ Are you trying to get pregnant? Yes
Have you taken any appetite-suppressing medication before? Yes__ _No__ _
If yes, please list all names & dosages:
Do you have or have ever had any psychiatric conditions: Yes_ __No_ __
If yes, please describe:
List any & all operations & dates:
No
Are you allergic to any medications: Yes___No___
If yes, please list all medications that you are allergic to and what your symptoms are:
List of current medications that you are taking: (use back of page if necessary)
Medication
Dosage
Frequency
I have answered the questions to the best of my knowledge.
Patient Name:
Patient Signature:
Date:
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Dr. Jeff Lester, D.O. – The Lester Clinic of Integrative Medicine
65 Aspen Way, Watsonville, CA 95076 ~ 831-724-1164 ~ [email protected]
3700 Thomas Rd. #207, Santa Clara, CA 95054 ~ 408-844-0010 ~ [email protected]
www.lesterclinic.com (general clinic) ~ www.calmwm.com (weight management)
CONSENT FOR MEDICAL WEIGHT LOSS TREATMENT
I herby authorize Dr. Lester to help me in my weight loss efforts. This may involve but not be limited to
medical history taking, in-office testing and physical examination, additional laboratory and other testing,
as indicated. I understand that my weight management treatment may consist of specific diet plans, a
balanced deficit diet, a protein-supplemented diet; recommendations for behavior modification techniques,
including prescribed regular exercise regimens; as well as the use of vitamins and supplements, and
appetite suppressant medications and therapeutic injections, as needed. All recommended medications
and injections at our clinic are safe and FDA-approved.
I understand that the success of the weight management program depends on my active participation. I
further understand that Dr. Lester cannot guarantee treatment success or any explicit outcome. I
understand that obesity is considered a chronic condition that may require permanent changes in my
eating habits and activities to achieve long-term success in this treatment.
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, high blood pressure, rapid heartbeat. Risks
associated with remaining overweight are tendencies of 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 and superimposing conditions.
I understand that my treatment is not covered by insurance and I am fully responsible for all costs
associated with my treatment. I further understand that the payment is paid in full at the time of visit. The
clinic does not provide any specific assistance to me in claims for reimbursement by insurance. Dr. Lester
and staff have explicitly explained to me the cost of each service and product. The payment is nonrefundable and non-transferable at any time during the treatment.
I acknowledge that as a patient, I am solely permitted to use the program all or in part for my own
personal use only. Dr. Lester warrants its ownership of the materials provided, and you are prohibited to
copy, duplicate, sell, lend or make any commercial use, to include but not limited to, program materials,
products, recipes.
I have read and thoroughly understand the entire contents of this consent form. I have also had the
opportunity to ask questions regarding these issues and herby acknowledge that my questions have been
satisfactory answered.
By signing below I authorize and direct Dr. Lester to provide treatment to me.
Patient Name: ___________________________________
Patient Signature: ________________________________
Date ____________________
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Dr. Jeff Lester, D.O. – The Lester Clinic of Integrative Medicine
65 Aspen Way, Watsonville, CA 95076 ~ 831-724-1164 ~ [email protected]
3700 Thomas Rd. #207, Santa Clara, CA 95054 ~ 408-844-0010 ~ [email protected]
www.lesterclinic.com (general clinic) ~ www.calmwm.com (weight management)
Acknowledgement of Receipt of
NOTICE OF PRIVACY PRACTICES
Effective as of April 14, 2003
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact our office.
This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance
Portability and Accountability Act (HIPAA). It describes how we may use or disclose your
protected health information, with whom that information may be shared, and the safeguards we
have in place to protect it. This notice also describes your rights to access and amend your
protected health information. You have the right to approve or refuse the release of specific
information outside of our system except when the release is required or authorized by law or
regulation.
ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE
You will be asked to provide a signed acknowledgment of receipt of this notice. Our intent is to
make you aware of the possible uses and disclosures of your protected health information and
your privacy rights. The delivery of your health care services will in no way be conditioned upon
your signed acknowledgment. If you decline to provide a signed acknowledgment, we will
continue to provide your treatment, and will use and disclose your protected health information
for treatment, payment, and health care operations when necessary.
By signing below, I certify that I have read and understood the Notice of Privacy Practices.
Patient Name:
Patient Signature:
Date:
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Dr. Jeff Lester, D.O. – The Lester Clinic of Integrative Medicine
65 Aspen Way, Watsonville, CA 95076 ~ 831-724-1164 ~ [email protected]
3700 Thomas Rd. #207, Santa Clara, CA 95054 ~ 408-844-0010 ~ [email protected]
www.lesterclinic.com (general clinic) ~ www.calmwm.com (weight management)