Name:
Age:
Sex: M F
Family
Physician: Phone:
Present Status:
1.
Are
you in good health at the present time to the best of your knowledge? Yes No
2.
Are
you under a doctor’s care at the present time? Yes No
If yes, for what?
3. Are you taking any medications at the present time? Yes No
What: Dosages:
What: Dosages:
4.
Any
allergies to any medications? Yes No
5.
History
of High Blood Pressure? Yes No
6. History of Diabetes? Yes No
At what age:
7.
History
of Heart Attack or Chest Pain? Yes No
8.
History
of Swelling Feet Yes
No
9. History of Frequent Headaches? Yes No
Migraines? Yes No Medications
for Headaches:
10. History of Constipation
(difficulty in bowel movements)? Yes No
11. History of Glaucoma? Yes
No
12. Gynecologic History:
Pregnancies: Number: Dates:
Natural Delivery or C-Section (specify):
Menstrual: Onset:
Duration:
Are they regular: Yes
No
Pain associated: Yes No
Last menstrual period:
Hormone Replacement Therapy: Yes No
What:
Birth Control Pills: Yes No
Type:
Last Check Up:
13. Serious Injuries: Yes No
Specify: Date:
14. Any Surgery: Yes No
Specify: Date:
Specify: Date:
15. Family History:
Age Health Disease Cause
of Death Overweight?
Father:
Mother:
Brothers:
Sisters:
Has any blood relative ever had any of
the following:
Glaucoma: Yes
No Who: Asthma: Yes
No Who:
Epilepsy: Yes
No Who:
High Blood Pressure Yes
No Who:
Kidney Disease: Yes No Who:
Diabetes: Yes
No Who:
Tuberculosis: Yes
No Who:
Psychiatric Disorder Yes
No Who:
Heart Disease/Stroke Yes
No Who:
Past Medical History: (check all that apply)
Polio Measles
Tonsillitis
Jaundice Mumps
Pleurisy
Kidneys Scarlet Fever Liver Disease
Lung Disease `
Whooping Cough Chicken Pox
Rheumatic Fever Bleeding Disorder
Nervous Breakdown
Ulcers Gout
Thyroid Disease
Anemia Heart Valve Disorder
Heart Disease
Tuberculosis Gallbladder Disorder
Psychiatric Illness
Drug Abuse Eating Disorder
Alcohol Abuse
Pneumonia Malaria
Typhoid Fever
Cholera Cancer Blood Transfusion
Arthritis Osteoporosis Other:
Nutrition Evaluation:
1.
Present
Weight: Height (no shoes): Desired Weight:
2.
In
what time frame would you like to be at your desired weight?
3.
Birth
Weight: Weight at 20 years of age: Weight one year ago:
4.
What
is the main reason for your decision to lose weight?
5.
When
did you begin gaining excess weight? (Give reasons, if known):
6. What has been your maximum lifetime weight
(non-pregnant) and when?
7. Previous diets you have followed: Give dates and
results of your weight loss:
8.
Is
your spouse, fiancee or partner overweight? Yes No
9. By how much is he or she overweight?
10. How often do you eat out?
11. What restaurants do you frequent?
12. How often do you eat “fast foods?”
13. Who plans meals? Cooks? Shops?
14. Do you use a shopping list? Yes No
15. What time of day and on what day do you shop
for groceries?
16. Food allergies:
17. Food dislikes:
18. Food you crave:
19. Any specific time of the day or month do you
crave food?
20. Do you drink coffee or tea? Yes No How much daily?
21. Do you drink cola drinks? Yes
No How much daily?
22. Do you drink alcohol? Yes No
What? How much? Weekly?
23. Do you use a sugar substitute? Butter? Margarine?
24. Do you awaken hungry during the night? Yes No
What do you do?
25. What are your worst food habits?
26. Snack Habits:
What? How much? When?
27. When you are under a stressful situation at
work or family related, do you tend to eat more? Explain:
28. Do you thing you are currently undergoing a
stressful situation or an emotional upset? Explain:
29. Smoking Habits: (answer only one)
You have never smoked cigarettes, cigars or a
pipe.
You quit smoking years ago and
have not smoked since.
You have quit smoking cigarettes at least one
year ago and now smoke cigars or a pipe without
inhaling smoke.
You smoke 20 cigarettes per day (1 pack).
You smoke 30 cigarettes per day (1-1/2
packs).
You smoke 40 cigarettes per day (2 packs).
30. Typical Breakfast Typical Lunch Typical Dinner
Time eaten: Time eaten: Time eaten:
Where: Where:
Where:
With whom: With
whom: With whom:
31. Describe your usual energy level:
32. Activity Level: (answer only one)
Inactive¾no regular physical activity
with a sit-down job.
Light activity¾no organized physical
activity during leisure time.
Moderate activity¾occasionally involved in
activities such as weekend golf, tennis, jogging,
swimming or cycling.
Heavy activity¾consistent lifting, stair
climbing, heavy construction, etc., or regular participation in jogging,
swimming, cycling or active sports at least three times per week..
Vigorous activity¾participation in extensive
physical exercise for at least 60 minutes per session 4 times per week.
33. Behavior
style: (answer only one)
You are always calm and easygoing.
You are usually calm and easygoing.
You are sometimes calm with frequent impatience.
You are seldom calm and persistently driving for advancement.
You are never calm and have overwhelming ambition.
You are hard-driving and can never relax.
34. Please
describe your general health goals and improvements you wish to make:
This information will assist us in assessing your
particular problem areas and establishing your medical management. Thank you
for your time and patience in completing this form.
___ ___ Loss of hearing
___ ___ Ringing in the ears
___ ___ Ear infection
___ ___ Bad vision
___ ___ Eye pain
___ ___ Eye infections
___ ___ Nose bleeds
___ ___ Sinus problems
___ ___ Sore throat
___ ___ Hoarseness
___ ___ Shortness of breath
___ ___ Back pain
___ ___ Rash
___ ___ Insomnia
___ ___ Memory loss
___ ___ Dizzy spells
___ ___ Palpitations
___ ___ Irregular pulse
___ ___ Swelling
___ ___ Feinting spells
___ ___ Chest pain
___ ___ Numbness
___ ___ Loss of appetite
___ ___ Indigestion
___ ___ Diarrhea
___ ___ Constipation
___ ___ Bloody or tarry stools
___ ___ Nervousness
___ ___ Depression
___ ___ Moodiness
___ ___ Phobias
___ ___ Hemorrhoids
___ ___ Blood in urine
___ ___ Frequent urination
___ ___ Hernia
___ ___ Sudden weight loss
___ ___ Fatigue
___ ___ Convulsions
___ ___ Headache
___ ___ Joint pain
Patient
Informed Consent for Appetite Suppressants
I. Procedure
And Alternatives:
1. I,_______________________________________________
(patient or patient’s guardian) authorize Dr. George C. Stege III to assist me
in my weight reduction efforts. I understand my treatment may involve, but not
be limited to, the use of appetite suppressants for more than 12 weeks and when
indicated in higher doses than the dose indicated in the appetite suppressant
labeling.
2. I have
read and understand my doctor’s statements that follow:
“Medications, including the
appetite suppressants, have labeling worked out between the makers of the
medication and the Food and Drug Administration. This labeling contains, among
other things, suggestions for using the medication. The appetite suppressant
labeling suggestions are generally based on shorter term studies (up to 12
weeks) using the dosages indicated in the labeling.
“As a bariatric physician, I
have found the appetite suppressants helpful for periods far in excess of 12
weeks, and at times in larger doses than those suggested in the labeling. As a
physician, I am not required to use the medication as the labeling suggests,
but I do use the labeling as a source of information along with my own
experience, the experience of my colleagues, recent longer term studies and
recommendations of university based investigators. Based on these, I have
chosen, when indicated, to use the appetite suppressants for longer periods of
time and at times, in increased doses.
“Such usage has not been as
systematically studied as that suggested in the labeling and it is possible, as
with most other medications, that there could be serious side effects (as noted
below).
“As a bariatric physician, I
believe the probability of such side effects is outweighed by the benefit of
the appetite suppressant use for longer periods of time and when indicated in
increased doses. However, you must decide if you are willing to accept the
risks of side effects, even if they might be serious, for the possible help the
appetite suppressants use in this manner may give.”
3. I
understand it is my responsibility to follow the instructions carefully and to
report to the doctor treating me for my weight any significant medical problems
that I think may be related to my weight control program as soon as reasonably
possible.
4. I
understand the purpose of this treatment is to assist me in my desire to
decrease my body weight and to maintain this weight loss. I understand my
continuing to receive the appetite suppressant will be dependent on my progress
in weight reduction and weight maintenance.
5. I
understand there are other ways and programs that can assist me in my desire to
decrease my body weight and to maintain this weight loss. In particular, a
balanced calorie counting program or an exchange eating program without the use
of the appetite suppressant would likely prove successful if followed, even
though I would probably be hungrier without the appetite suppressants.
II. Risks of
Proposed Treatment:
I
understand this authorization is given with the knowledge that the use of the
appetite suppressants for more than 12 weeks and in higher doses than the dose
indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry
mouth, weakness, tiredness,
psychological problems, medication
allergies, high blood pressure, rapid heart beat and heart irregularities. Less
common, but more serious, risks are primary pulmonary hypertension and valvular
heart disease. These and other possible risks could, on occasion, be serious or
fatal.
III. Risks
Associated with Being Overweight or Obese:
I am
aware that there are certain risks associated with remaining overweight or obese.
Among them are tendencies to high blood pressure, to diabetes, to heart attack
and heart disease, and to arthritis of the joints, hips, knees and feet. I
understand these risks may be modest if I am not very much overweight but that
these risks can go up significantly the more overweight I am.
IV. No
Guarantees:
I
understand that much of the 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 I will have to continue watching my weight
all of my life if I am to be successful.
V. Patient’s
Consent:
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, or any questions I have
concerning them have not been answered to my complete satisfaction. I have been
urged to take all the time I need in reading and understanding this form and in
talking with my doctor regarding risks associated with the proposed treatment
and regarding other treatments not involving the appetite suppressants.
WARNING
IF YOU HAVE ANY QUESTIONS AS TO 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:___________________________________
PATIENT:_________________________________WITNESS:_______________________________
(or person with authority to consent for patient)
VI. PHYSICIAN
DECLARATION:
I have
explained the contents of this document to the patient and have answered all
the patient’s related questions, and, to the best of my knowledge, I feel the
patient has been adequately informed concerning the benefits and risks
associated with the use of the appetite suppressants, the benefits and risks
associated with alternative therapies and the risks of continuing in an
overweight state. After being adequately informed, the patient has consented to
therapy involving the appetite suppressants in the manner indicated above.
____________________________________________________
Physician’s
Signature
I ______________________________________ authorize
Dr. George C. Stege III, Family Care Group of Kentuckiana P.S.C. 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 much of the 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)
Welcome
to our weight loss program! The program consists of three parts: diet,
exercise, and medication.
Diet
We
recommend a low fat reduced calorie diet. We will provide you with
additional information on a low fat diet, and the doctor will give you specific
recommendations on how many fat grams you should eat each day. We do recommend
three well balanced meals a day with no between meal snacking.
Exercise
We
recommend aerobic exercise to help you lose weight. We have free low
impact aerobic classes as a service for our patients. We will provide a map to
these classes. We recommend at least 30 minutes of aerobic exercise three times
a week for cardiovascular fitness. If you are extremely overweight, water
aerobics are another alternative.
Medication
Several
types of appetite suppressants are available to assist you in losing weight.
These medications will only suppress your appetite; to lose weight you must eat
less. The doctor will prescribe the one that is most appropriate for you. We have
additional information on the medications available on request. The
physician will answer any questions you have about the risk and benefits of
using medication. In order to reach a healthy weight, it may be necessary to
use medication in ‘off-label’ duration, indication, or combinations.
In
order to ensure your safety in taking any medication, it is important that we
obtain a complete medical history and perform a physical exam. Some
medical conditions such as high blood pressure or heart disease such as angina
preclude the use of medication. Also, if you have a history of drug or
alcohol abuse it is not safe for you to take medication. If you are pregnant or
think you may be pregnant you must not take any medication. You must also let
us know if you are allergic to any medication. You must not exceed the
prescribed dose of any medication. Doing so would put you at risk of heart
attack, stroke, or death. You also should check with the office before taking
any over the counter medicine with prescription medication. You must let us
know if you are taking any prescription medicine from any other physicians.
While participating in our diet program you must not see any other physician
for similar medication as this may put you at risk for serious side effects or
drug dependency and may be against the law. Also be aware that it is against
the law to sell or give your medication to any other person. If you have taken
any diet medication in the past you must also inform us of this.
To
be eligible for medication you must be overweight. Being significantly
overweight increases your risk of many serious medical problems. The physician
will calculate your ideal weight based on your height, your frame size, and
your percentage of body fat. You must also have tried to lose weight on your
own first. To continue medication you must lose weight. If you experience
any side effects or problems please call the office. Dry mouth, constipation,
mild elevations of heart rate and slight nervousness are the most common side effects
and are not of concern. Shortness of breath, chest pain, leg swelling, fainting
spells, or elevated blood pressure should be reported immediately.
I
have read all of the information above and agree to these terms.
_________________________________________________________
Date _____________________
NEW PATIENT MEDICAL INFORMATION
Date:____________________________________________
Name:______________________________________
Age:_______________________________________
Do you have any medical
problems? ٱ High blood pressure
ٱ Diabetes
ٱ Asthma
________________________________
________________________________
________________________________
Have you had any
surgeries? ٱ
Appendix
ٱ Gall Bladder
ٱ Hysterectomy
Are you allergic to any
medicines? ٱ Penicillin
________________________________
Please list any
medicines you take: ________________________________
________________________________
Please list any
hospitalizations: ________________________________
Do any diseases run in
your family? š Diabetes
š