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Program Registration
drcroland
2014-12-04T09:27:56-05:00
Medical Weight Loss Program Registration
New Patient Weight Loss Registration
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Name
*
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Last
Email
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Enter Email
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Address
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Armed Forces Americas
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ZIP Code
Birth Date
*
MM slash DD slash YYYY
Your gender?
*
Female
Male
Driver license number
*
Required for prescribing medication
License State
*
State of issuance
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Which of our locations would you prefer?
*
Matthews office
Ballantyne office
How did you hear about us?
*
Referred by my medical provider
Referred by a friend of family member
Atrium/CHS Perks
Novant Employee Perks
Web search
Facebook or other social media
Radio
Yelp
Other
Please tell us the name of the physician or medical provider who referred you.
*
Please tell us the name of your friend or family member who referred you.
*
We have a program in place to reward patients who refer others to us. Please let us know the name of one person who referred you.
Which search engine did you use to find us?
*
Google
Bing
Yahoo
Yelp
Aol
Other
How did you learn of our services?
*
How tall are you in inches (NOT FEET) (please see example below)
*
60 inches = 5 feet | 64 inches = 5 feet 4 inches | 69 inches = 5 feet 9 inches
Please enter a number from
48
to
78
.
How much do you currently weigh? (best estimate)
*
BMI - Current estimate
What is your highest weight ever? (non-pregnant)
*
BMI - Highest
What is your ULTIMATE weight goal?
*
My weight gain has been:
*
sudden
gradual
My struggle with weight started:
*
during childhood
in my teens
in my 20's
in my 30's
after age 40
Have you ever participated in a MEDICAL weight loss program in the past?
*
Yes
No
Which weight loss program and what medications did you take?
*
ie. doctors name, clinic name. medications, injections.
I believe the following factors may have contributed to my weight problem:
*
Please check all that apply.
poor dietary choices
I skip meals, then overeat
I consume too much sugar (ie. sweet tea, regular soda)
I eat fast food 2 or more times per week
lack of structured exercise
I usually sleep less than 7 hours per night
I consume too much alcohol
I quit using tobacco products
anxiety or depression
medications or illness
pregnancy
hormone imbalance
I have no idea why I am gaining weight.
Do you currently experience any of the following symptoms?
*
Sugar cravings
Symptoms of low blood sugar or hypoglycemia
Frequently wake up feeling hungry
Skin tags
Increased facial hair
Acne
Increased thirst or urination
Decreased energy / increased fatigue
Abnormal periods
Swelling of extremities
Frequent constipation
Excessively dry skin
Frequent heartburn or reflux
Recent chest pain
Heart palpitations
Increasing or frequent shortness of breath
None of these
Please check all that apply.
How often do you exercise?
*
hardly ever
1-2 times per week
3-4 times per week
5 or more times per week
Are you allergic to any medications, supplements, latex?
*
Yes
No
Please list what you are allergic to and what type of reaction you have
*
What are you allergic to?
Reaction?
ie. Sulfa-throat swells, etc.
Do you regularly take any medications or supplements?
*
Yes
No
Please list your current medications, supplements and dosages
*
Medication or supplement
Dosage
Times per day
Have you ever had major surgery or been hospitalized?
*
Yes
No
Please list past major surgeries or hospitalizations
*
Surgery or hospitalization
Approximate date
Have you ever had an electrocardiogram (EKG)?
*
Yes
No
Approximate date of last EKG
*
Have you ever been told you had abnormalities on an EKG?
*
Yes
No
Please comment on any EKG abnormalities.
*
Medical History
Have you ever been diagnosed with the following?
(do not include family history in this section)
Have you ever been diagnosed with the following?
*
Glaucoma (Narrow-Angle requires ophthalmologist release)
Gallbladder problems
High blood pressure
Heart conditions including heart attack, coronary artery disease, arrhythmias (irregular heartbeats), valvular heart disorders or heart murmurs
Wolf-Parkinson-White (WPW)
Stroke or mini-stroke
Seizures / epilepsy
Sleep apnea
Diabetes or gestational diabetes
Infertility
Thyroid disease
Personal history of cancer
Psychiatric disorder requiring hospitalization
Bipolar disorder
Attention Deficient Disorder (A.D.D.)
Narcolepsy
Alcohol or drug problems
Anorexia or bulimia
Panic disorder
HIV / AIDS / Hepatitis
Kidney stones
Polycystic ovaries (PCOS)
Migraine type headaches
None of the above
What type of heart problems have you had?
*
examples: angina, heart attack, heart failure, valve disorder, blockage of vessels, etc.
Are you currently on Insulin?
*
Yes
No
What type of thyroid problem have you had?
*
Which substances did you have problems with?
*
Please specify the type of cancer
*
Have you ever taken medication for Attention Deficit Disorder, Narcolepsy or Chronic Fatigue?
*
Yes
No
Please list all medications ever taken for ADD/ADHD/Narcolepsy/Chronic Fatigue
*
Family History
Family Medical History
*
Do the following illnesses run in your family? (Parents, grandparents, siblings, children only.)
Heart disease
Diabetes
Thyroid disease
Cancer
Death before age 50
Stroke
Obesity
I am unsure of my family history
None of the above
Please give us more detail about family cancers
*
Family member
Type of cancer
More details about early death
*
Family member
Cause of death
Age at time of death
Which family members have struggled with their weight?
*
Mother
Father
Grandparent
Children
Please select all that apply
Social History
Marital status
*
Single
Married
Divorced
Widowed
Do you currently use tobacco or nicotine products?
*
Yes
No
How many alcoholic drinks do you have per week? (include liquor, beer, wine)
*
I don't ever consume alcohol
0-1 drink per week
2-6 drinks per week
7-10 drinks per week
more than 10 drinks per week
Are you trying to get pregnant or is there a chance you may be pregnant?
*
Yes
No
Date of your last period
*
MM slash DD slash YYYY
Are you currently breast feeding?
*
Yes
No
Have you had a mammogram?
*
Yes
No
Date (approximate) and result of your most recent mammogram
*
Financial and Practice Policies
Do you currently receive Medicare benefits, either due to age or disability?
*
Yes
No
Agreement To Practice Policies
*
I understand that this Practice does not participate with any government or private medical insurance plans. All fees are due at the time of service. Many clients do utilize their flex spending (FSA) and HSA bank cards. It is the responsibility of the client to follow all IRS guidelines when using these accounts for payment. Fees are listed on our website and are subject to change without notice. Also, please be aware that any dietary products and supplements that are sold from our facilities are carefully selected by our staff. As in any business enterprise, such items are typically sold at a profit. There is never any obligation to purchase products at our facility. We do not participate in any federally sponsored health insurance programs (i.e. Medicare or Medicaid) or commercial insurance plans and we do not submit claims or fill out insurance forms. We do provide receipts at the time of service. Since we do reserve one hour for your initial visit, we do require a deposit of $75 to hold the appointment. This fee is fully refundable so long as written notice to cancel is received with a minimum notice of two business days. While we offer many therapeutic options through our weight loss programs, final determination for prescribing appetite suppressants is based on BMI and/or body fat percentage, patient's medical history and other findings. If you do not qualify for controlled appetite suppressants by regulatory guidelines, you will not be eligible for that particular therapy. We will typically check the North Carolina Controlled Substance Reporting System on any new patient to be sure there is no conflict with patient reported medication history. Any dishonesty or willful omission will disqualify patient from receiving services and no refunds will be offered. By signing below, you attest that the above information is true and complete.
Please type full name to AGREE with Policies above
*
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