Thursday, May 24, 2012

New Patient Paperwork

The documents below can be printed and filled out before you come into the clinic.

Consultation Information Sheet
Personal Information
 Last Name
First Name
Middle Initial
Date of Birth
Weight /Height
Zip Code
Home Phone
Cell Phone
Email Address


O None

O Unknown

Medical Allergies:


O None
O Unknown
O Angina
O Arrhythmia
O Cardiomyopathy
O Congenital
O Implanted Defib
O None
O Unknown
O Abdominal
O Heart
O Lung
O Neurological
Chronic Illnesses
O None
O Asthma
O Bleeding Disorder
O Cancer-Any
O Cyst-Any
O Diabetic
     O Type 1
     O Type 2
O Dialysis/Renal
O Gall Bladder
O Gastrointestinal
O Gout
O Headaches
O Hepatitis
O Hypertension
O Paralysis
O Psychological
O Seizures
O Substance Abuse
O Unknown
Current Medications AND Medical Conditions in the Past Year
O None O Unknown _________________________________________________________





Past Medical History
Emergency Contact Information
 Primary Physician
Physician Phone Number
Primary Contact Name & Relationship
Primary Contact Phone Numbers

Previous Methods of Weight Loss

How did you hear about us?


Please Select Program Options of Interest
O HCG Injections                                                    OHCG Nasal Spray
O Hypnosis                                                             O HCG Cream
O HCG Oral Drops                                                  O Prescription Weight Loss Aids
O Non-HCG Weight Loss                                        O Body Sculpting
O Exercise                                                               O Other __________________________________
O One on One Weight Loss Counseling                               __________________________________
O Group Weight Loss Counseling                       

______________________________________           _____________________________
Patient Signature                                                            Staff Representative Signature

__________________________________                   _____________________________
Date                                                                                Date

Terms of Agreement

In order to obtain the best results possible with Diet by Design, I understand and agree to comply with the following program guidelines: 
·      I will attend weekly counseling appointments.  I will meet in the office a minimum of twice a week with a counselor, and check in for counseling either by phone or email contact at least once a week.
·      I will purchase the prescribed amount of nutritional protein supplements and/or products for my weight loss program.
·      I will be compliant with the program by consuming all prescribed nutritional protein supplements and products, amounts of water, as well as consume only what is recommended on the meal plans.
·      I understand that light physical activity, weekly group hypnosis sessions, and reading the educational material provided by Diet by Design are included for obtaining the best possible permanent weight loss results.
·      I will lose at least 10 pounds per month, an average of 2.5 pound per week.  I do understand that this is an average and based on my initial consultation if I do not meet the average, I may need more than the originally anticipated weeks of weight loss.
·      I will follow the terms of the general agreement of program participation and attendance set forth by Diet by Design.  
·      I understand that when purchasing my program the necessary products are included for the estimated length of my program. Once I receive any product Diet by Design is not responsible for any lost, ruined, stolen, or otherwise unusable product. I understand that I will be responsible for replacing my products at my own expense in the case that the initial products are lost, ruined, stolen, expired, etc.
·      I understand I must use my program weeks consecutively.
·      I understand that I have one year from the date of purchase to complete my program. 
·      I understand that I am responsible for the costs and expenses related to lab work and a physician review of my lab results. I understand that there are no refunds for those fees.
·      I understand that I have 6 months from the time of my initial lab tests to complete my program. If I have not completed the weight loss phase within 6 months, I will be responsible for the cost of having the lab tests repeated.

I have read, understand, and agree to the terms of this agreement. Diet by Design has a no refund policy for programs costs or product purchases.

Signature of participant                                                         Date

Signature of Diet by Design Representative                     Date


All persons who desire to use Diet by Design’s Fitness/Exercise Facilities must complete this form.

No one under the age of fourteen (14) may use the fitness/exercise facility or equipment at any time.

Refer to your initial fitness assessment paperwork for additional policies, regulations, and guidelines.

Use of fitness/exercise facilities and equipment are at the user’s sole risk and responsibility.
All users are advised and encouraged to consult with his/her personal physician before beginning use of fitness or exercise facilities and/or equipment or participating in any physical activity.

In consideration of being given the option to use the fitness/exercise facility and/or equipment, for myself and my family, heirs, executors, representatives, administrators, and assigns, I hereby waive, release, and forever discharge the Davisson Clinic and Diet by Design  and its respective officers, directors, employees, agents, and affiliated organizations from and against any and all claims, liabilities, and causes of action, whether foreseeable or unforeseeable, which may at any time arise out of or relate in any manner, directly or indirectly, to my use of said fitness/exercise facility and/or equipment or participation in any services or programs related thereto. This waiver and release shall include, but not be limited to a release of all claims, liabilities, and causes of action which may arise at any time in connection with any personal or other injury to myself or others, or death caused by or related to my use of said
Fitness/exercise facilities and/or equipment or participation in any services or programs related thereto.

My signature hereby affirms that I have fully and completely read, understand, and agree to this waiver and release and all contents thereof.

Print Name:  _________________________                                               
Date:  __________

Signature:___________________________                                                Date:___________

Parent/Guardian Signature:_______________                                          Date:___________

Witness:____________________________                                      Date:___________

This is your medical history form, to be completed prior to you beginning your program. All information will be kept confidential. This information will be used for the evaluation of your health and readiness to begin our program. Please take your time and complete it carefully and thoroughly.  Your answers will help us design a comprehensive program that meets your individual needs.
Name        ________________________________________________________________

Address   ________________________________________________________________

Contact phone numbers ____________________________________________________

Birth date_______________________________________________________________                  
Family Physician and/or Primary Health Care Provider:

Doctor/Other___________________________      Phone ___________________________

Address   ______________________________      City _____________________________
May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?
     Yes                                        No

Marital Status:
     Single                                 Married                                     Divorced                               Widowed
     Male                                    Female
Position ______________________________      Employer ________________________

Address   ________________________________________________________________

Phone       ________________________________________________________________
Present Medical History
Check those questions to which you answer yes (leave the others blank).
¨  Has a doctor ever said your blood pressure was too high?
¨  Do you ever have pain in your chest or heart?
¨  Does your heart often race?
¨  Are your ankles often badly swollen?
¨  Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary?
¨  Do you suffer from frequent cramps in your legs?
¨  Do you often have difficulty breathing?
¨  Do you get out of breath long before anyone else?
¨  Has a doctor ever told you your cholesterol level was high?
Comments: __________________________________________________________________



Do you now have or have you recently experienced:
¨  Problems with recurrent fatigue, trouble sleeping or increased irritability?
¨  Migraine or recurrent headaches?
¨  Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation, or diarrhea?
¨  Pregnant/Breast Feeding?
¨  Ovarian Cyst
¨  Prostate or Testicular Cancer
¨  Gout
¨  Gall bladder/Gastrointestinal issues
¨  Kidney disease
¨  Heart Disease
¨  Type 1 Diabetes
¨  Bypass Surgery
¨  Organ Transplant
Comments: __________________________________________________________________



Women only answer the following. Do you have?
¨  Menstrual period problems?
¨  Significant childbirth - related problems?
Date of the last pelvic exam and / or Pap smear _______________________________________

Comments: __________________________________________________________________

Are you on any type of hormone replacement therapy?_________________________________

Men and women answer the following:
List any prescription medications you are now taking: _________________________________



List any over the counter medications, dietary supplements, or vitamins you are now taking:__



Date of last complete physical examination: _________________________________________
    Normal                             Abnormal                               Never                                     can’t remember

List any other medical or diagnostic test you have had in the past two years: _______________


List hospitalizations, including dates of and reasons for hospitalization within the last two years:             


List any drug allergies:__________________________________________________________

Past Medical History
Check those questions to which your answer is yes (leave others blank).
¨  Heart attack if so, how many years ago? ________
¨  Diabetes or abnormal blood-sugar tests
¨  Phlebitis (inflammation of a vein)
¨  Dizziness or fainting spells
¨  Epilepsy or seizures
¨  Stroke
¨  Thyroid problems
¨  Jaundice or gall bladder problems

Comments: __________________________________________________________________

What do you consider a good weight for yourself? _____________________________________

What is the most you have ever weighed (including when pregnant)? _____________________

One year ago my weight was:________

How often do you drink alcoholic beverages?

     None                                    Occasional                              Often                              If often, _____ per week

Comments: __________________________________________________________________


_____________________________                         _______________________
Patient Signature                                                                       Staff Signature

_______________________                                        ______________________
Date                                                                                              Date

Media Release Agreement

I, ______________________________the undersigned, do hereby consent and agree that Davisson Clinic Diet by Design, its employees, or agents have the right to take photographs, videotape, or digital recordings of me and to use these in any and all media, now or hereafter known, and exclusively for the purpose of DIET BY DESIGN.  I further consent that my name and identity may be revealed therein or by descriptive text or commentary.
I do hereby release to Davisson Clinic Diet by Design, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.
I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.
I also understand that Davisson Clinic Diet by Design is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.
I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

Name:                                                                                      Date:                                       
Witness for the undersigned:                                                                                                    

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