Better Life™ Medical Weight Loss

Better Life™ Medical Weight Loss - Patient Registration
Miss
Ms.
Gender:
M
F
Last Name:
First:
Birth Date:
/
/
Age:
Middle:
Div
Part
Which Doctor, if any, referred you?
E-mail Address:
Address:
Marital Status:
Single
Mar
Sep
Wid
Office Use Only
Mr.
Mrs.
Dr.
Chart
Date
Entered
Entered By:
Address 2:
City:
State:
Zip:
Weight:
Phone Number:
Mobile Number:
Fax Number:
Goal Weight:
Occupa�on:
Employer:
Work Number:
How did you hear about Be�er Life™ Medical Weight Loss?
Billboard
Coupon
Direct Mailing
Employee
Internet
Doctor
Newspaper
Pa�ent / Friend
Radio
T.V.
Walk-In
Other:
What Radio Sta�ons Do You Listen To:
KOA - 850 AM
KNUS - 710 AM
KRFX - 103.5 FM (THE FOX)
KXKL - 105.1 FM (KOOL-105)
KTCL - 99.3 FM
KWOF - 92.5 FM (THE WOLF)
KOSI - 101.1 FM
KALC - 105.9 FM (Alice)
KIMN - 100.3 FM
KBPI - 106.7 FM
KBCO - 97.3 FM
KXPK - 96.5 FM (THE PEAK)
Magazine
KQKS - 107.5 FM (KS 107.5)
KPTT - 95.7 FM (THE PARTY)
KRKS - 94.7 FM
KQMT - 99.5 FM (THE Mountain)
KYGO - 98.5 FM
Other _______________________
Primary Physician (if any):
Physician Phone Number:
Emergency Contact
Local Friend / Rela�ve:
Insurance Information
Phone:
Rela�onship:
Work:
Medical insurance policies do not typically cover weight management care and related expenses, including laboratory tes�ng,
electrocardiograms, prescrip�on medica�on and related supplements. Be�er Life™ Medical Weight Loss will not present a bill to any
insurance company for weight management services or related charges. You have the op�on to submit the cost of services on your own.
Tax Information
Un�l 2002, taxpayers were only allowed to claim the cost of doctor-recommended weight-loss treatment for such problems as heart
disease and hypertension. The IRS offers a tax break for qualifying pa�ents. Details of this tax break are in IRS Publica�on 502, Medical
and Dental Expenses. Learn more at h�p://www.irs.gov/taxtopics/tc502.html.
Payment Information
Be�er Life™ Medical Weight Loss accepts Visa, MasterCard, Discover, American Express, and cash. We do not accept insurance
or personal checks.
Stress Level Information
Number of children at home:
Spouses occupa�on:
Where you live:
own a home
rent a house
rent an apartment
Weight loss programs you have tried:
None
Slimgenics
Jenny Craig
Weight Watchers
Nutrisystem
Curves
Other: __________________
Women Only
Date of last menstrua�on?
Are you pregnant, trying for pregnancy, or breast feeding?
YES
NO
Are you currently using birth control?
YES
NO
© 2011 Aspen Life Sciences Corpora�on
Page 1 of 4
www.Be�erLifeClinics.com
Better Life™ Medical Weight Loss - Patient Registration
All ques�ons contained in this history form are strictly confiden�al and will become part of your medical record on file.
Last Name:
First Name:
Health History
Alcohol Abuse
Anemia
Arthri�s
Asthma
Bleeding Disorder
Bloody Stool
Bipolar Disorder
Bronchi�s
Cancer
Chest Pain
Cons�pa�on
Convulsions
Depression
Diabetes
Diarrhea
Dizzy Spells
Drug Abuse
Ea�ng Disorder
Epilepsy
Fain�ng Spells
Fa�gue
Frequent Urina�on
Gallbladder Disorder
Glaucoma
Headaches
Heart Disease
High Cholesterol
Hypertension
Insomnia
Personal
Family
Personal
Family
Personal
Family
Complete to the best of your knowledge.
Irregular Pulse
Kidney Disease
Liver Disease
Lung Disease
Mental Illness
Migraines
Moodiness
Nervousness
Obesity
Palpita�ons
Rashes
Shortness of Breath
Stroke
Thyroid Disease
Comments / Other:
Surgergies & Other Hospitalizations
Year
Reason / Diagnosis
Allergies: Medication & Food
Medica�on or Food Name
Hospital
Reac�on
Prescribed Medications & Over-the-Counter drugs, dietary supplements (including vitamins, inhalers, etc)
Medica�on Name
Strength
Frequency
© 2011 Aspen Life Sciences Corpora�on
Page 2 of 4
www.Be�erLifeClinics.com
Better Life™ Medical Weight Loss - Patient Registration
All ques�ons contained in this history form are strictly confiden�al and will become part of your medical record on file.
Last Name:
First Name:
Behavior Style
Please select only one answer.
You are always calm and easygoing.
You are usually calm and easygoing.
You are some�mes calm and easygoing
You are seldom calm and persistently
driving for advancement
You are never calm and have
overwhelming ambi�on
You are hard driving and never relax.
Health Habits & Personal Safety
All answers will be kept strictly confiden�al.
Exercise
Sedentary (no exercise)
Mild Exercise (i.e., climbing stairs, walking three blocks, golf)
Occasional vigorous exercise (i.e., work or recrea�on less than 4 �mes per week for 30 minutes)
Alcohol
Caffeine
Diet
Regular vigorous exercise (i.e., work or recrea�on 4 �mes per week or more for 30 minutes or more)
Are you die�ng?
Yes
No
If yes, are you on a physician prescribed medical diet?
Yes
No
How many meals do you eat in an average day?
Rank your salt intake:
High
Medium
Low
Rank your fat intake:
High
Medium
Low
Medium
Low
None
Coffee
Tea
Soda
Yes
No
Liquor
Wine
Yes
No
Rank your caffeine intake:
High
What types of caffeine do you drink?
How many cups/cans per day?
Do you drink alcohol?
If yes, what kind?
Beer
How many drinks per week?
Tobacco
Do you use tobacco?
Cigare�es – packs/day:
Chew – #/day:
Pipe – #/day:
Cigars – #/day:
How many years?
Drugs
If you previously used tobacco, what year did you quit?
Do you currently use recrea�onal or street drugs?
Yes
No
Have you ever taken street drugs with a needle?
Do you take Ephedra or Sudafed??
Yes
No
Yes
No
Patient Statement of Understanding
I have read and fully understand the above informa�on related to insurance and par�cipa�on in Be�er Life™ Medical Weight Loss. I have
also had the opportunity to ask ques�ons regarding these issues. I understand that it will be my responsibility to follow-up on these
issues with my primary care physician. I am aware that I will receive an appropriate receipt of payment for my personal use as I see fit to
do so. I accept these specific policy rules. I understand that today’s visit with the clinician is for consulta�on purposes . I will disclose
medical issues to today’s clinician and I will be truthful in the informa�on I disclose. No treatment is implied or given at today’s visit other
than the specialized therapy I am recieving today (i.e. Weight Loss Therapy). I agree to follow up for any ongoing medical or new medical
issues with my regular doctor. I understand that the medical field is constantly changing and there may be new treatments available for my
ongoing chronic diseases. I will not stop taking any medica�ons prescribed by my regular doctor without no�fying my regular doctor first as
well as no�fying Be�er Life. By signing below I agree to follow up with my primary care physician. If I have not seen a doctor recently, I
agree to follow up with a doctor within 30 days. I AGREE THAT THE INFORMATION ON MY MEDICAL FORM REGARDING CURRENT OR PAST
MEDICAL HISTORY OR CONDITIONS IS TRUTHFUL.
Date:
Pa�ent / Guardian Signature:
Printed Name:
© 2011 Aspen Life Sciences Corpora�on
If you are a guardian, what is your rela�onship to the pa�ent?
Page 3 of 4
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Better Life™ Medical Weight Loss - HIPAA Notice of Privacy Practices
This no�ce describes how medical informa�on about you may be used and disclosed and how you can get access to this informa�on.
Please review it carefully.
This No�ce of Privacy Prac�ces describes how we may use and disclose
your protected health informa�on to carry out treatment, payment,
and healthcare opera�ons, and for other purposes that are permi�ed
or required by law. It also describes your rights to access and control
your protected health informa�on. Protected Health Informa�on, or
PHI, is informa�on about you, including demographic informa�on, that
may iden�fy you and that relates to your past, present, or future
physical or mental health or condi�on and related healthcare services.
Other Permi�ed & Required Uses and Disclosures
Disclosures will be made only with your authoriza�on or opportunity
to object unless required by law. You may revoke this authoriza�on at
any �me, in wri�ng, except to the extent that your physician or the
physician’s prac�ce has taken an ac�onin reliance on the use or
disclosure indicated in the authoriza�on.
Treatment
We will only use and disclose your protected health informa�on to
provide, coordinate, or manage your health care and related services.
This includes the coordina�on or management of your health care with
a third party. For example, we would disclose your protected health
informa�on, as necessary, to a home health agency that provides you
care to you, or provide it to a physician whom you have been referred
to ensure that the physician has the necessary informa�on to diagnose
or treat you.
2. You have the right to request a restric�on on the disclosure of
your protected health informa�on. This means you may ask us
not to use or disclose any part of your protected health
informa�on for the purposes of treatment, payment or
healthcare opera�ons. You may also request that any part of
your protected health informa�on not be disclosed to family
members or friends whom may be involved in your care or for
no�fica�on purposes as described in this No�ce of Privacy
Prac�ces. Your request must state the specific restric�on
requested and to whom you want the restric�on to apply. Your
physician is not required to agree to a restric�on that you may
request. If a physician believes it is in your best interest to permit
use and disclosure of our protected health informa�on, your
health informa�on will not be restricted. You then have the right
to use another healthcare professional.
Your Individual Rights:
1. You have the right to inspect and receive a copy of your
Uses and Disclosures of Protected Health Informa�on
protected health informa�on. Our prac�ce will accept such
Your protected health informa�on may be used and disclosed by your
requests in wri�ng. Under federal law, however, you may not
physician, our office staff, and others outside of our office that are
inspect or receive a copy of the following records; psychotherapy
involved in your care and treatment for the purpose of providing
notes; informa�on compiled in reasonable an�cipa�on of, or use
health care services to you, to pay your health care bills, to support the in, a civil, criminal, or administra�ve ac�on or proceeding; and
opera�ons of the physicians prac�ce, and any other use required by
protected health informa�on that is subject to law that prohibits
law.
access to protected health informa�on.
Payment
Your protected health informa�on will be used as needed to obtain
payment for your health care services.
Healthcare Opera�ons
We may use or disclose, as needed, your protected health informa�on
in order to support the business ac�vi�es of your physician’s prac�ce.
These ac�vi�es include but are not limited to quality assessment,
employee review, training of medical students, and licensing. For
example, we may call you be name in the wai�ng room when your
physician is ready to see you. We may use or disclose your protected
health informa�on, as necessary, to contact you to remind you of your
appointments.
We may use or disclose your protected health informa�on in the
following situa�ons without your authoriza�on: as required by law,
public health issues, communicable diseases, health oversight, abuse
or neglect, food and drug administra�on requirements, legal
proceedings, law enforcement, coroners, funeral directors, organ
dona�on, research, criminal ac�vity, military ac�vity, and na�onal
security. Under the law, we must also make disclosures to you, and
when required by the Department of Health and Human Services to
inves�gate or determine our compliance with the requirements of
Sec�on 164.500.
3. You have the right to request to receive confiden�al
communica�ons from us by an alterna�ve means or at an
alterna�ve loca�on.
4. You have the right to obtain a paper copy of this no�ce from us.
5. You have the right to receive an accoun�ng of certain disclosure
we have made, if any, of your protected health informa�on. We
reserve the right to change the terms of this no�ce and will post
any changes in our wai�ng areas. You then have the right to
object as provided in this no�ce.
Complaints
You may file any complaints with Be�er Life™ Medical Weight Loss at
(720) 239-1300, or with the Secretary of Health and
Human Services if you believe your privacy rights have been violated
by us. We will not retaliate against you for filing a complaint.
Better Life™ Medical Weight Loss - Receipt of Notice of Privacy Practices
Chart
Be�er Life™ Medical Weight Loss reserves the right to modify the privacy prac�ces outlined in this no�ce.
By signing below, I am indica�ng that I have received a copy of the No�ce of Privacy prac�ces for Be�er Life™ Medical Weight Loss.
Printed Name:
© 2010 Be�er Life Clinics, Inc.
Pa�ent Signature:
Page 4 of 4
Date:
www.Be�erLifeClinics.com