Patient Profile Name Sex M F Date of Birth SSN Contact

Patient Profile
Name
Sex
Date of Birth
M
F
SSN
Contact Information
Email
Mobile Phone
Work Phone
Street Address
City
State
Zip Code
Emergency Contact
Name
Relationship
Primary Care Physician
Phone
Phone
How did you hear about us?
Insurance Information
Carrier
Contact Number
Group Number
Policy Number
Policy Holder’s Name
Policy Holder’s Date of Birth
Policy Holder’s SSN
Employer
Personal Weight History
Height
Current Weight
Goal Weight
Lifetime Max Weight
When did you last weigh your goal weight?
How much weight do you expect to lose with Bariform?
Page 1 of 13
Diet History
Name
Date of Birth
Method
Your results: how
long did you maintain
your weight loss?
(ex: 10 lbs lost, 2 months)
How long did you
follow the diet?
Please provide dates.
Why did you stop?
(ex: desired other foods)
Any problems
during diet?
(ex: dizziness)
Weight Watchers®
Atkins Diet™
South Beach Diet
Jenny Craig®
Nutrisystem®
Doctors’ Diet Program
Physician Supervised
Diets
Prescription Diet
Medication
Unsupervised Diets
(Slim Fast®, Calorie or
Carb Counting)
Other
Other
Which method of weight loss do you consider most successful for yourself?
Comments
Page 2 of 13
Medical History
Previous Surgeries or Hospitalizations
Drug Allergies
Medical Conditions
! Abnormal Periods
! Acid Reflux
! Asthma
! Current or Planned Pregnancy
! Depression/Mental Health
! Diabetes: type 1 type 2
! Eating Disorder
! Glaucoma
! Heart Disease
! High Blood Pressure
! High Cholesterol
! Hormones/Birth Control
! Hypokalemia (low potassium)
! Insomnia
! Kidney Disease
! Liver Disease
! Lung Disease
! Polycystic Ovarian Syndrome
! Sleep Apnea
! Thyroid Disorder
!
!
!
!
Family Medical History
Disease
Relation
! Cancer
! Diabetes
! Heart Disease
! High Cholesterol
! Obesity
! Stroke
! Sudden Death < 40 years old
Page 3 of 13
Current Medications
Medication
Dose & Frequency
Social History
Smoke / Tobacco Use:
! never
! former
! current – everyday
! current – some days
Alcohol Use:
! never
! former
! current – everyday
! current – some days
Drug Use:
! never
! former
! current – everyday
! current – some days
Psychosocial History
Are you at present undergoing any major lifestyle changes (ex: marriage, divorce, job change, death of family
member, etc.)?
What other commitments do you have that might interfere with your full participation in Bariform’s program?
What benefits do you hope to gain from being in Bariform’s program other than losing weight?
Who do you feel will be supportive of your weight loss and lifestyle changes? Please circle all that apply.
spouse
children
roommate
coworkers
parents
friends
other
Page 4 of 13
Who do you feel may not be supportive of your weight loss and lifestyle changes? Please circle all that apply.
spouse
children
roommate
coworkers
parents
friends
other
List 5 reasons you think it is important for you to lose weight. Please list in order of importance, with 1 being the most
important to you.
1.
2.
3.
4.
5.
Why did you choose this particular program?
Have you ever experienced a dramatic change in mood while dieting?
Have you ever been severely depressed?
Have you ever had suicidal thoughts?
Lifestyle and Eating Habits
How many meals do you typically eat out per week?
Are the majority of these meals with family or friends?
Are these meals usually fast food (ex: McDonald’s)?
questionnaire continued on next page
Page 5 of 13
Of the following, check all that you feel help explain or describe your eating habits:
! Thinking about food too much
! Eating high fat foods
! Eating too many sweet foods
! Eating in reaction to tension/depression ! Uncontrollable binges
! Eating too quickly
! Using food as a reward
! Overeating at social events
! Lack of satisfaction in life
! Eating in reaction to boredom
! Overeating when alone
! Eating to take mind off problems
! Not paying attention to what I’m eating
!
!
!
!
!
! Cocoa
! Milk protein
! Corn
! Soy
! Eggs
! Other
! Other
! Other
! Other
Are you allergic to:
Are you sensitive to or do you have problems with:
! Aspartame (Nutrasweet)
! Monosodium Glutamate (MSG)
! Lactose (unable to drink milk but able to eat cheese and yogurt)
questionnaire continued on next page
Page 6 of 13
Diet Readiness Questionnaire
SECTION 1: GOALS AND ATTITUDES
1. Compared to previous attempts, what is your level of motivation to lose weight this time?
1 – NOT AT ALL
2 – SLIGHTLY
3 – SOMEWHAT
4 – QUITE MOTIVATED
5 – EXTREMELY MOTIVATED
2. How certain are you that you will stay committed to the weight loss program for the time it takes to reach your
goal?
1 – NOT CERTAIN AT ALL
2 – SOMEWHAT CERTAIN
3 – UNCERTAIN
4 – CERTAIN
5 – EXTREMELY CERTAIN
3. Consider all outside factors at this time in your life (work stressors, family obligations, etc.) To what extent can you
tolerate the effort required to stick to a diet?
1 – CANNOT TOLERATE
2 – SOMEWHAT
3 – UNCERTAIN
4 – CAN TOLERATE WELL
5 – CAN TOLERATE EASILY
questionnaire continued on next page
Page 7 of 13
SECTION 2: HUNGER AND EATING CUES
1. When food comes up in a conversation, do you want to eat even if not hungry?
1 – NEVER
2 – RARELY
3 – OCCASIONALLY
4 – QUITE MOTIVATED
5 – EXTREMELY MOTIVATED
2. Do you have trouble controlling your eating when your favorite foods are in your home?
1 – NEVER
2 – RARELY
3 – OCCASIONALLY
4 – OFTEN
5 – ALWAYS
3. Do you eat more than you would like when you have negative feelings such as anger, depression, or stress?
1 – NEVER
2 – RARELY
3 – OCCASIONALLY
4 – OFTEN
5 – ALWAYS
4. Do you have trouble controlling your eating when you have positive feelings? Do you celebrate feeling good by
eating?
1 – NEVER
2 – RARELY
3 – OCCASIONALLY
4 – OFTEN
5 – ALWAYS
questionnaire continued on next page
Page 8 of 13
5. When you have unpleasant interactions with others or a high stress day, do you eat more than you would like?
1 – NEVER
2 – RARELY
3 – OCCASIONALLY
4 – OFTEN
5 – ALWAYS
If the following situations occurred while you were on a diet, would you be more likely to eat less or more immediately
afterward and for the rest of the day?
1. Although you planned on skipping lunch, a friend talks you into going out for a midday meal.
! Likely to eat more
! Likely to eat less
2. You “break” your diet by eating a “forbidden food.”
! Likely to eat more
! Likely to eat less
3. You have been following your diet faithfully and decide to test yourself by eating something you consider a treat.
! Likely to eat more
! Likely to eat less
FOR OFFICE USE ONLY
Height
Weight
BP
Pulse
Chest
Waist
Hips
Thighs
Goal Weight
Page 9 of 13
Informed Consent for Treatment
Medical weight loss is an important decision in your health care. We are informing you through lectures and printed materials that we will work
with you carefully and safely to help you achieve a medically significant weight loss. To achieve this loss and help you maintain long term
success, Bariform may prescribe various nutritional plans, exercise programs, and when appropriate, the use of medication. You will be
informed as to how the medications work, possible side effects and consequences, dietary, and exercise activities planned. The use of some
medications and their dosing may be used in an “off label” manner - the physician may prescribe medications to be used differently than
initially approved by the FDA. The use of medication will always be within the scope of accepted medical bariatric medicine. The use of
medications for weight loss is optional and no weight loss treatment, including use of medications, guarantees successful weight loss.
Your Role
1. Provide honest and complete answers to questions about your health, weight issues, eating activity, medication or drug usage, and
lifestyle patterns to help us help you.
2. Devote the time and effort necessary to complete and comply with the course of treatment.
3. Allow us to share information with your personal physician if necessary.
4. Make and keep follow-up appointments so that we may help you the best, allowing necessary blood tests as needed.
5. Advise the clinic staff and the physician of any concerns, problems, complaints, symptoms or questions you develop.
6. Inform your personal physician of your weight loss efforts; have or establish a primary care physician prior to beginning this program.
Possible Side Effects
1. Reduced weight. By reducing your caloric intake, you may see a variety of temporary and reversible side effects including, but not
limited to, increased urination, momentary dizziness, reduced metabolic rate, cold sensitivity, slower heart rate, dry skin, fatigue,
constipation, diarrhea, bad breath, muscle cramps, changes in menstrual pattern, dry or brittle hair, or hair loss. Medication side effects
may include any of the above plus dry mouth, mild headaches, and very rarely a racing or pounding heart rate or an elevation in blood
pressure and other more rare side effects. This will be closely monitored, as safety is our number one priority.
2. Reduced potassium levels or other electrolyte abnormalities. We monitor electrolyte levels and will correct them if they become too low.
If not corrected, this can result in muscle cramps, heart rhythm irregularities and other symptoms as above. Always inform us if you are
on or begin a water pill. We will be following your electrolyte levels with occasional blood testing.
3. Gallstones. Overweight and obese patients are at risk for having or developing gallstones. Studies report that 1 in 10 persons entering a
weight loss program may have silent or undiagnosed gallstones. Active weight loss can produce new stones or cause established stones
to develop symptoms. Pain is usually in the right upper abdomen and may spread to the back. Gallbladder problems may require
medications or possible surgery. Notify your primary doctor or Bariform if you develop symptoms of gallstones including abdominal pain,
fever, nausea, and vomiting.
4. Pancreatitis. Inflammation of the bile ducts or pancreas gland may be associated with gallstones and may be precipitated by eating a
large meal after a period of strict dieting. It may require hospitalization and rarely can be associated with life threatening complications.
Notify Bariform or your primary care physician if you develop symptoms such as pain in the left upper abdominal quadrant, fever, or
vomiting.
5. Pregnancy. Notify us if you become pregnant. Overweight female patients may have irregular ovulation. Weight loss may increase
ovulatory regularity and the chance of becoming pregnant. If pregnant, you must change your diet to avoid further weight loss. A
restricted diet can damage a developing fetus. Any weight loss medications must be discontinued if pregnancy occurs. Take precautions
to avoid becoming pregnant during weight loss treatment.
6. Sudden death. Overweight and obese patients, especially those with associated high blood pressure, diabetes, or heart disease, have a
higher risk of sudden death and development of a serious - potentially fatal disease - known as Primary Pulmonary Hypertension. Rare
instances of sudden death have occurred while obese patients are undergoing weight loss. No cause and effect relationship with the diet
program and sudden death has been established.
7. Risk of weight regain. Obesity is a chronic condition. The majority of patients who lose weight have a tendency to regain unless a
maintenance program and long-term efforts at controlling their weight are continued. We will provide you with a maintenance plan to
help prevent weight regain.
Patient Signature
Date
Page 10 of 13
Statement of Patient Financial Responsibility
Patient Name
DOB
Bariform Medical Group appreciates the confidence you have shown in choosing us to provide for your health care needs. The
service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure
payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. You are
ultimately responsible for payment of your bill. Payment is required at the time services are rendered unless you are covered by
an insurance company with which Bariform participates. We accept payment in the form of cash, check or credit card.
You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your
insurance carrier. We expect these payments at time of service. Many insurance companies have additional stipulations that
may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance carrier denies
any part of your claim, or if you or your physician elects to continue past your approved period, you will be responsible for your
balance in full.
I have read the above policy regarding my financial responsibility to Bariform Medical Group, for providing services to me or the
above named patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to
pay any benefits directly to Bariform Medical Group, the full and entire amount of bill incurred by me or the above named patient;
or, if applicable any amount due after payment has been made by my insurance carrier.
Patient Signature
Date
Guarantor Signature
Date
(If guarantor is not the patient)
Co-Pay Policy
It is the policy of the Bariform Medical Group that patients are prepared to pay their required co-payment at the time service is
rendered.
Patient/Guarantor Signature
Date
Cancellation / No Show Policy
24 hours cancellation notice is required if you are unable to keep your appointment. All no show appointments will be charged a
$25.00 fee due prior to next appointment.
I have read and understand the above information, and I agree to the terms described:
Patient/Guarantor Signature
Date
Self-Pay Policy
I do not have health insurance and will be responsible for services rendered at Bariform Medical Group. I agree to pay Bariform
Medical Group the full and entire amount of treatment given to me or to the above named patient at each visit.
Patient/Guarantor Signature
Date
Page 11 of 13
Your Rights and Confidentiality
You have the right to leave treatment at any time without any penalty. It is the patient’s responsibility to inform Bariform that they
are discontinuing treatment. Your personal physician must be able to assume your medical care.
Occasionally patient treatment information is used to compare results and improve the treatment of obesity. This information may
be shared with other practitioners, researchers, and the scientific and medical community. Strict confidentiality of individual
personal information and records will be maintained.
HIPAA
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED
AND DISCLOSED AND HOW YOU MAY ACCESS THIS INFORMATION
USES AND DISCLOSURES OF INFORMATION THAT WE MAY MAKE WITHOUT WRITTEN AUTHORIZATION:
For treatment, payment, healthcare operations, as required by law, abuse or neglect, or communicable diseases, public health
activities, health oversight activities, judicial and administrative proceedings, law enforcement, organ donation, research, workers
compensation, appointments and services, marketing, business associates, military, inmates or person in police custody.
USES AND DISCLOSURES OF INFORMATION THAT WE MAY MAKE UNLESS YOU OBJECT:
We may use and disclose protected health information in the following instances without your written authorization unless you
object. If you object, please notify the Privacy Contact identified at the end of this document.
PERSONS INVOLVED IN YOUR HEALTH CARE:
Unless you object, we may disclose protected health information to a member of your family, relative, close friend, or other
person identified by you who is involved in your health care or the payment for your health care. We will limit the disclosure to
the protected health information relevant to that person’s involvement in your health care or payment. We may leave messages
for you to call us or leave basic lab test results on your home phone unless you direct otherwise.
NOTIFICATION:
Unless you object, we may use or disclose protected health information to notify a family member or other person responsible
for your care of your location and condition.
Person(s) Authorized to Receive Information
Physician Office(s) Authorized to Receive Medical Information
YOUR RIGHT CONCERNING YOUR PROTECTED HEALTH INFORMATION:
You have the following rights concerning your protected health information. To exercise any of these rights, you must submit a
written request to our Privacy Officer.
1. To request additional restrictions.
2. To receive communications by alternative means.
3. To inspect and copy records.
4. To request amendment to your record.
5. To request accounting of certain disclosures.
6. To receive a copy of our complete confidentiality notice.
7. To receive a copy of the bill to submit to your insurance. We will code your visit as medically correct as possible. Please
note in rare instances a new diagnosis or prescription that you submit to your insurance may affect your insurability and or
your insurance rates.
Page 12 of 13
COMPLAINTS:
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated.
You may file a complaint with us by notifying our Privacy Officer. All complaints must be in writing. We will not retaliate against
you for filing a complaint.
ENTITIES TO WHOM THIS NOTICE APPLIES:
This notice applies to Bariform, the associated clinics, physicians, employees, and volunteers.
PRIVACY OFFICER CONTACT:
If you have any questions about this notice, would like to request a copy of the complete notice or if you want to object to or
complain about any use of disclosure or exercise any right as explained above, please contact our active Medical Director at
317 Seven Springs Way, Suite 205, Brentwood, Tennessee 37027
I, the undersigned, have reviewed this information on the front and the back page of this document, and have had an
opportunity to ask questions and have them answered to my satisfaction. I understand that payment is due at time of service. I
understand Bariform physicians have additionally opted out of Medicare payment benefits, thus Medicare may not reimburse you
for services provided here.
Signature
Date
Page 13 of 13