Patient Intake Packet | Arnold Medical Weight Loss

Section 1 of 8

About you

Let’s start with the basics. Fields marked * are required.

Your name

Last name *

Please enter your last name.

First name *

Please enter your first name.

M.I. optional

Nickname optional

Date of birth and sex

Date of birth *

Please enter a valid date of birth.

Sex assigned at birth *

Female Male

We ask because some medications in this program are not safe during pregnancy, so the consent forms differ. If you would like to tell us the name or pronouns you use, add them under Nickname above or tell us at your visit.

Please choose one.

How did you hear about us?

Choose the one that fits best.

Please tell us more

Social Security number optional

You can leave this blank and give it to us at the office instead. We only use it for your medical record.

SSN

Format: 000-00-0000

Please enter 9 digits, or leave this blank.

Section 2 of 8

Contact & emergency

Where to reach you, and who to call if we can’t.

Your address

Street address *

Please enter your street address.

Apt / Suite optional

City *

Please enter your city.

State *

Two-letter state, please.

ZIP code *

Please enter a valid ZIP code.

How to reach you

Cell phone *

Please enter a 10-digit phone number.

Home phone optional

Please enter a 10-digit phone number, or leave blank.

Email *

Please enter a valid email address.

Best way to reach you about appointments

Call my cell Text me Call my home Email me

We will only use this for appointment and refill reminders.

Emergency contacts

Please give us at least two people we can contact, plus your physician.

Contact 1 *

Full name *

Please enter a name.

Relationship *

Please enter a relationship.

Phone *

Please enter a 10-digit phone number.

Contact 2 *

Full name *

Please enter a name.

Relationship *

Please enter a relationship.

Phone *

Please enter a 10-digit phone number.

Your physician

Physician name

Practice or clinic

Physician phone

Please enter a 10-digit phone number, or leave blank.

Section 3 of 8

Medical history

Answer to the best of your knowledge. Your clinician will go over all of it with you.

Current health

1. Are you in good health at the present time, to the best of your knowledge? *

Yes No

If no, please explain

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

List all prescription and over-the-counter drugs

Allergies

Are you allergic to any medications? *

Yes No

If yes, which ones — and what happens?

Please tell us which medications.

Any history of the following?

Questions 4 through 12 from the paper packet.

Surgeries

13. Have you had any surgery? *

Yes No

List the type and approximate date of each

Section 4 of 8

Past & family history

Check anything that applies, then tell us what you know about your family.

Your past medical history

Check all that apply. Leave the rest blank.

Anything else we should know?

Your family medical history

To the best of your ability. Leave anything you don’t know blank — a guess is worse than a gap.

Section 5 of 8

Nutritional evaluation

This section shapes the dietary instruction you get. The more honest it is, the more useful your plan will be.

Your goal

1. What is the main reason for your decision to lose weight? *

Please tell us your main reason.

Current weight (lb) *

Please enter a weight in pounds.

Height *

Please enter your height.

2. Desired weight (lb) *

Please enter a target weight.

3. In how many months?

Your weight history

4. Weight at age 20 (lb)

Weight one year ago (lb)

6. Most you have weighed (lb)

Not counting pregnancy.

When?

5. When did you begin gaining excess weight? Give reasons if you know them.

7. Is your spouse, fiancé(e), or partner overweight?

Yes No N/A

Approximately how much overweight?

How you eat now

8. How often per week do you eat out?

9. How often per week do you eat fast food?

10. Foods you are allergic to

11. Foods you strongly dislike

12. Foods you crave

13. Times of day or month you crave food

14. Do you drink coffee or tea?

Yes No

How much daily?

15. Do you wake up hungry during the night?

Yes No

How often?

16. Previous diets you have followed — name or description, and your results

Section 6 of 8

Lifestyle considerations

Three questions.

Alcohol

1. Do you drink alcohol? *

Yes No

If yes, how often?

Daily Weekly Occasionally

Roughly how many drinks?

Tobacco 2. Tobacco smoking habits *

Have never smoked Currently smoke Quit smoking

Please choose one.

Quit how many years ago?

How much per day?

Activity level

3. Choose the one that best describes you now — not what you hope to be doing.

Inactive — no regular physical activity, sit-down job Light activity — no organized physical activity during leisure time Moderate activity — occasional weekend golf, tennis, jogging, and the like Heavy activity — consistent lifting or stair climbing, or regular jogging or swimming 3× per week Vigorous activity — extensive exercise, at least 60 minutes per session, 4× per week

Please choose one.

Section 7 of 8

Consents & acknowledgements

Please read each one. Take all the time you need — and do not sign anything you have questions about. Call 636-333-2235 and ask first.

Financial policy

Informed consent for appetite suppressants

Procedure and alternatives

I authorize Dr. J. W. Campbell and whomever he designates as his assistants 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. 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.
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 (see “Risks” 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 used in this manner may give.
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.
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.
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 suppressant.

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.

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.

No guarantee

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.

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.

Patient (or guardian) signature *

Sign here with your finger, stylus, or mouse

Not signed

By signing above you agree that this electronic signature is the legal equivalent of your handwritten signature. The date, time, and your device’s network address are recorded with it.

Please sign before continuing.

HIPAA privacy notice

Consent to treatment — patients who can become pregnant

Section 8 of 8

Review & submit

Check everything over. Use the Edit links to fix anything, then submit.

Confirm and sign

Final signature *

Sign here with your finger, stylus, or mouse

Not signed

By signing above you agree that this electronic signature is the legal equivalent of your handwritten signature. The date, time, and your device’s network address are recorded with it.

Please sign before continuing.

How this is sent. Your packet travels to us over an encrypted connection, is turned into a PDF, and is stored encrypted on our server. It is never emailed. Read the Privacy & HIPAA Notice.

New Patient Intake Packet

About you

Contact & emergency

Medical history

Past & family history

Nutritional evaluation

Lifestyle considerations

Consents & acknowledgements

Review & submit

Your packet is on its way