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DR. GEOFF MEDICAL WEIGHT LOSSCLIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTSI have requested and authorized DR. GEOFF MEDICAL WEIGHT LOSS to assist me in myweight reduction efforts. I understand that my treatment may involve, but not be limited to theuse of appetite suppressants.I understand that if after my initial consultation, I decided that I do not want to participate in theprogram, or should the physician/nurse practitioner determine that based on the exam the use ofappetite suppressants is not indicated, I will not be eligible for a refund.I understand it is my responsibility to follow all instructions carefully and to report to theprovider treating me all medical problems or symptoms that I feel may be related to my weightcontrol program as soon as they occur.I understand that discontinuation of pharmacological agents may occur at any time under myhealth care providers discretion.I acknowledge that in initiation therapy there are potential risks involved:1. Most common side effects include, but are not limited to: Nervousness, OverStimulation, Restlessness, Dizziness, Headache, Dry Mouth, and Anxiety, Changesin Mood, Rapid Heart Rate, and Medication Allergies (rash, hives).2. Increased Blood Pressure.3. Developing primary pulmonary hypertension.4. Potential of causing birth defects.5. Increased difficulty in controlling diabetes, hypertension, and other chronicdiseases.6. Developing Regurgitant Cardiac Valvular disease.7. Adverse effects may occur with altering the dose or stopping my medicationswithout first consulting my doctors.I have read and fully understand this consent form. I have had the opportunity to discuss anyquestions about my weight control program. My provider has answered all of my questions.XCLIENT SIGNATUREDATETIMEWITNESSMEDICAL BOARD NUMBERGBM044Client Informed Consent for Appetite Suppressants11/18
ooooooSITE:GibsoniaGreensburgIndianaIrwinPenn HillsYEARLY CLIENT UPDATE SHEETName:Address:Email Address:Date of Birth:Preferred # to CallHome #:Cell #:Work #: If we need to contact you for any reason:May we call and/or leave a message on your home phone and home voice mail?May we call and/or leave a message on your cell phone and cell voice mail?May we call and/or leave a message on your work phone and work voice mail?May we contact you in writing at the address above (ex. via US Mail)?May we contact you via the email address above?YYYYYorororororNNNNNPreferred Method of contact?EMERGENCY CONTACT:If we need to contact you and can’t reach you by one of the above, methods, who may we calland leave a message with (name and number(s))?1.2.Who may we discuss your personal health information with? This information will only beabout the weight loss program (name and number(s)).1.2.CLIENT SIGNATURE:DATE COMPLETED:GBM043YEARLY CLIENT UPDATE SHEET11/18
Dr. GEOFF MedicalWeight LossCLIENT WEIGHT LOSSHISTORY QUESTIONNAIREGibsoniaGreensburgIndianaIrwinPenn HillsDay: DATE:NAME:ADDRESS:HOME PHONE: BUSINESS PHONE:PLEASE COMPLETE THE FOLLOWING (STRICTLY CONFIDENTIAL):1. When did you begin to gain weight? After childbirth After marriage After an employment change During a stressful period Other8. Why have you dropped out of diets before? Boredom Hunger Stress Need assistance Others16. Do you work outside thehome? No Part-time Full-timeOccupation2. How long have you been overweight? 1 year or less 2-5 years 6-10 years 10 years9. What is the nature of your difficultieswhile dieting?17. Sex: Female Male18. Age: Under 1810. Are you under a physician’s care? 18-24 Yes No 25-343. What do you feel is the reason for your 11. Have you been advised by your physician to 35-49weight problem?lose weight? 50-64 Frequently overeating Yes No Over 64 Enjoy fattening foods12. Do you have any physical problems that Lack of activityyou know are associated with your weight? 19. Marital Status: Heredity Married Other Divorced Single4. How many meals do you eat daily?13. Why do you want to lose weight? Widowed Promotes social activity Living with a partner Appearance20. Number of children:5. How many serious attempts have you Special occasion (please list)Ages:made at dieting?21. Are any of your children Health reasonsoverweight?6. How long have you been able to To please family/friends22. What is your current weight?stick to a diet? Otherlbs. 1-2 months14. Has your husband or wife encouraged23. What was your highest 2-6 monthsyou to lose weight? Yes Noweight in the last 5 years? 7-12 monthsExplain:lbs. Over 12 months24. What was your lowest weightin the last 5 years?7. What other weight reduction method15. How important is it to you to lose weight?lbs.have you tried? Extremely important25. What is your target weight? Weight Watchers Very importantlbs. Other diet centers Important Diet books Not very important PhysiciansGBM020Client Weight Loss History Questionnaire11/18
Dr. GEOFF MedicalWeight LossClient HISTORYGibsoniaGreensburgIndianaIrwinPenn HillsDay: DATE:HISTORY FORMName (print) PhoneAddress DOBAgePrimary Physician SexMD Address MD Phone #AllergiesCurrent Medication(s)HT WT BP BMIPERSONAL DATA1. Have you or any blood relative ever had any of the following conditions?CONDITIONYESNOWHENCLIENTBLOOD RELATIVEArthritisAsthmaBone peGlaucomaGoutHeart Disease(describe)High BPKidney Problems(describe)Liver Problems(describe)Lung ProblemsMigrainePsychiatric Problems(describe)SeizuresThyroid ProblemsUlcerOtherGBM026-1Page 1 of 211/18
Client HISTORY (PAGE 2)Client Name Date2. Have you ever had surgery? Yes NoType and Date:3. Do you smoke cigarettes/cigar/chew? Yes NoIf yes, Amt: Day/Week/Month (circle one)4. Did you ever smoke? Yes No When did you quit?How long did you smoke?5. Do you drink beer, distilled spirits or wine? Yes NoIf yes, Amt: Week/Month/Year (circle one)6. Female: Are you pregnant? Yes No Could you possibly are pregnant?Yes No Are you Breast-Feeding? Yes No7. Have you ever been on a diet program before? Yes NoWhat program? When:Were medications prescribed? Yes NoIf yes, what medications?8. Are you currently taking any Over-The-Counter diet medication, and if so, what?9. Have you Gained/Lost more than 15lbs. in the last year? Yes NoIf yes, how many lbs Gained Lost10. How did you hear about our program?11. Do you take Over-The-Counter medications? Yes NoIf yes, please complete the following:CONDITIONSMEDICATIONHOW OFTENAllergiesColdsHeadachesInsomniaPain (where?)OtherClient Signature:Staff Signature:GBM026-2Page 2 of 211/18
DR. GEOFF MEDICAL WEIGHT LOSS CLIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS I have requested and authorized DR. GEOFF MEDICAL WEIGHT LOSS to assist me in my weight reduction efforts. I understand that my treatment may involve, but not be limited to the use of appetite suppressants.
