New Patient Form
PATENT INFORMATION FORM
PATIENT NAME: LAST___________________FIRST________________MI___
PATIENT ADDRESS_________________________________________________
CITY_____________________________STATE_________ZIP_______________
HOME PHONE_____________________CELL____________________________
E-MAIL____________________________________________________________
BIRTH DATE_____________________AGE______SEX M
F
EMPLOYMENT INFORMATION
PATIENT EMPLOYER________________________OCCUPATION___________
EMPLOYER ADDRESS_______________________________________________
CITY___________________________________STATE_______ZIP___________
WORK PHONE NO__________________________EXTENSION_____________
IN CASE OF EMERGENCY
NAME___________________________________RELATIONSHIP____________
PHONE__________________________________
PATIENT'S SPOUSE_______________________PHONE____________________
FAMILY PHYSICIAN______________________PHONE____________________
HOW DID YOU HEAR ABOUT OUR PRACTICE:
INTERNET_____YELLOW PAGES_____
PHYSICIAN (PLEASE NAME) ________________________________________
FRIEND (PLEASE NAME)____________________________________________
OTHER (PLEASE NAME)_____________________________________________
Nova ABC Weight Loss Center requires a $75 deposit to reserve an initial
appointment with the doctor. This charge will be applied to your first visit; or is
fully refundable as long as the office is given no less than 24 hours’ notice of
cancelation. IF YOU ARE CALLING TO CANCEL AFTER HOURS. YOU
CAN LEAVE A MESSAGE ON THE MACHINE BY DIALING 703-494-1020
AND PRESSING #8
In addition, there will be a $50 charge in the event that a patient makes and
cancels the first appointment and then reschedules a second appointment and fails
to keep that second appointment. In this event the 24 hour rule is waived. YOU
MUST KEEP THE SECOND APPOINTMENT IN ORDER TO AVOID THE
$50 CHARGE. THERE WILL BE NO EXCEPTIONS TO THIS RULE.
We offer prepaid weekly and bi-weekly visits at a discounted rate THESE
VISITS EXPIRE, the weekly prepaid visits are good for 5 weeks and the
biweekly are good for 6 weeks.
I have read and understand the above and agree to these terms.
______________________
_______________
SIGNATURE
DATE
FIRST APPOINTMENT REQUIREMENTS
PLEASE DO NOT WEAR ANY OILS, LOTIONS, OR CREAM THE DAY
OF THE TEST
LABWORK
CMP, CBC, LIPID PANEL, FREE T4, URIC ACID, TSH, PHOS
PREP FOR METABOLIC TEST:
NO EXERCISE OF CAFFEINE THE DAY OF THE APPOINTMENT
4 HOUR FAST (NOTHING BUT WATER) PRIOR TO THE TEST
New Patient Privacy Forms
Northern Virginia Area Bariatric Consultants Privacy Practices
This notice describes the way in which medical and personal information pertaining to
you may be used and disclosed. It also, explains how you can access your health
information. Please review it carefully and sign the attached acknowledgement receipt at
the bottom of this notice and return it to the receptionist.
At Northern Virginia Area Bariatric Consultants the staff is committed to the protection
of your private health information. Within our office access to your information is
limited to those employees who need access in order to perform their jobs.
Northern Virginia Area Bariatric Consultants may use and disclose protected health
information in order to facilitate treatment, collect payments and for internal healthcare
operations. Examples of these include, but are not limited to referral to other healthcare
providers, life insurance physicals, and home healthcare agencies. Payment examples
include your health insurance provider for claims and coordination of benefits,
workman's compensation or similar programs: Collections agencies, etc. Healthcare
operations include auditing of records and internal quality control.
Northern Virginia Area Bariatric Consultants is required by law to use and/or disclose
protected health information without the patients' written consent or authorization in
certain circumstances. These include reporting a crime, responding to a subpoena,
warrant or court order; public health officials concerned with controlling disease,
disability and injury.
Northern Virginia Area Bariatric Consultants may use or disclose protected health
information to your personal representative whom you have authorized to act on your
behalf in making decisions related to your health care.
NOVA ABC Weight Loss Clinic will contact patients at phone numbers provided to us by
the patient in order to give appointment reminders or other information regarding
treatment and/or tests results.
NOVA ABC Weight Loss Clinic will not use or disclose a patients protected health
information as is described in this notice without the individual's written
authorization. This authorization may be revoked at any time in writing. Exceptions are
those described above as required by law.
NOVA ABC Weight Loss Clinic will abide by this notice which is currently in effect as of
April 14, 2003, at the time of disclosure. We reserve the right to revise the terms of this
notice and make new provisions effective for all protected health information we
maintain.
NOVA ABC Weight Loss Clinic will keep a posted copy of our current privacy practices
in our lobby area. Copies of this notice may also be obtained at any time in our office.
Any person/patient, who believes their privacy rights have been violated, may register a
complaint with our office manager at 703-494-1020; and to the Secretary of Health of
Human Services.
It is our office policy that no retaliatory action will be made against any individual who
submits a complaint of non-compliance of the privacy standards
You have the legal right to inspect copies of your protected health information. This
requires a written, signed and dated request. (as allowed by State law, reasonable copy
fees may apply)
If you believe your health information is inaccurate or incomplete, you may request to
amend your information. In the event that we deny your request, we will inform you of
our reasons for such a denial in writing.
You have the legal right to request restrictions on certain uses of your protected health
information as provided by 45CFR 154.522(a). By law we are not required to comply
with a requested restriction.
Acknowledgement of Privacy Practices:
I have received a notice of privacy practices, outlining my rights regarding my protected
health information and the specific ways in which my private health information may be
used and disclosed as allowed under state and federal law.
Patient or legal Representative___________________________Date_____________
Relationship of above if not signed by patient_________________________________
In the event patient refused to sign________________________________________
Document by________________________________________________________
WEIGHT LOSS CONSENT FORM
I_______________________________authorize Dr William C. McCarthy and his staff at
Northern Virginia Area Bariatric Consultants to help me in my weight reduction
efforts. I understand that my program may consist of a balanced 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 no 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______________________
Weight-Loss Consumer Bill of Rights
WARNING: Rapid weight loss may cause serious health problems. Rapid weight loss is
weight loss of more than 1 1/2 pounds to 2 pounds per week or weight loss of more than 1
percent of body weight per week after the second week of participation in a weight loss
program. Consult your personal physician before starting any weight loss program. Only
permanent lifestyle changes such as making healthful food choices and increasing
physical activity, promote long-term weight loss. Qualifications of this provider are
available upon request. You have the right to ask questions about the potential health
risks of the program and its nutritional content, psychological support, and educational
components; receive an itemized statement of the actual or estimated price of the weight
loss program, including extra products, services, supplements, examinations and
laboratory tests; know the actual or estimated duration of the program.
I have read the above:
Patient's Signature_______________________________Date_______________
Release of Medical Records
I give permission for my medical records (blood work, chart, EKG) to be release to:
Name_________________________________________________
Signature__________________________Date_____________________________
"BEFORE" AND "AFTER" PHOTOS
I_____________________________________, give my permission for NOVA ABC to take
my "before" and "after" photographs. (photographs will not be used for advertising
without patient permission)
Signature____________________________________________________________
PATIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS
I. Procedure and Alternatives:
1. I______________________________________(patient or patient's guardian)
authorize Dr. William C. McCarthy 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 the 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 the
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 and 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 heartbeat 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.
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___________________
(can be signed by legal guardian if patient is a minor)
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_________________________________________________
NOVA ABC Hours of Operation and Cancellation Policy
We make every effort to make sure your visits are pleasant and efficient for you. Please
make every effort to arrive at your appointment on time. If you are unable to make your
scheduled time just call and notify our office. (AFTER HOURS YOU CAN LEAVE A
MESSAGE ON OUR PHONE) Or email us at novaabc@novaabc.com Our patient
hours are as follow:
Monday
12:30 pm -7 pm
Tuesday
12:30 pm -7 pm
Wednesday
6:30 am -11:30 am
Thursday
6:30 am -1 pm
Friday
6:30 am-10 am
Phone hours are available to make appointments between 9 am - 4 pm Monday-Tuesday,
9 am - 2 pm Wednesday-Thursday and Fridays between 6:30am - 12 pm (these hours are
subject to change depending on staff availability)
If you need to miss an appointment please call 24 hours in advance to cancel in order to
avoid a $50.00 no-show fee. Again you can call after hours and leave a message on our
answering machine. Our phone number is 703-494-1020 and press #8 to leave a
message.
I ACKNOWLEDGE THE ABOVE MENTIONED NO-SHOW POLICY AND
UNDERSTAND I WILL BE CHARGED $50.00 FOR FAILURE TO GIVE 24 HOURS
NOTICE TO THE OFFICE OF CANCELLATION.
______________________________________
_________________________
NAME
DATE
New Patient History Forms
NOVA ABC Medical History Form
Name: ________________________________ Age: ___________________
Sex: M F (circle one)
Family Physician: ______________________ Phone: _________________________
Present Status:
1. Are you in good health at the present time to the best of your knowledge? Y
2. Are you under a doctor’s care at the present time? Y
N
N
If yes, for what? ________________________________________
3. Are you taking any medications at the present time? Y
N
What: ______________________ Dosage: ___________________
What: ______________________ Dosage: ___________________
4. Any allergies to any medications? Y
N
What: _________________________________________________
5. History of high blood pressure? Y
N
6. History of pre-diabetes or diabetes? Y
N
At what age? ___________________________________________
7. History of heart attack or chest pain? Y
8. History of swelling feet? Y
N
N
9. History of frequent headaches? Y
N
Migraines? Y___ N ___ Medications for headaches: __________
10. History of sleep apnea? Y___ N___ Have you ever had a sleep study?
Y
N
Result:
Do you snore? Y___ N___ Have you been told you quit breathing while sleeping? Y___ N___
Do you fall asleep while driving, riding in a car >30 min, reading, or watching TV?
Describe __________________________________________________________________
11. History of constipation (difficulty in bowel movement)? Y N
12. History of glaucoma? Y
N
13. Gynecologic history:
Pregnancies: Number: _________Dates: _____________________________________________
________________________________________________________________________________
Is there any chance of pregnancy now? Y___ N___
Natural delivery or C-Section (specify): _____________________
Complications of pregnancy (e. g. gestational diabetes, preeclampsia, eclampsia, etc.)
Describe: _______________________________________________________________________
________________________________________________________________________________
Menstrual: Onset Age: _____ Regular: Y___ N___
If periods are not regular (not regular, excessively heavy, etc.), please
describe_________________________________________________________________________
________________________________________________________________________________
Have you ever been diagnosed with polycystic ovary syndrome? Y___ N___
Pain associated: Y___ N___ Last menstrual period: ___________
Hormone Replacement Therapy: Y
N
What: __________________________________________
Birth Control Pills: Y N
Type: _________________________________________________
Last Checkup:__________________________________________
14. Serious Injuries: Y
N
Specify: ____________________________________________________________________
15. Any surgery: Y N
Specify: _________________________________ Date: _____________________________
Specify: _________________________________ Date: _____________________________
16. Family History:
Age Health Disease Cause of Death Overweight?
Father: ________________________________________________________________________
Mother: _______________________________________________________________________
Brothers: ______________________________________________________________________
Sisters: ________________________________________________________________________
Has any blood relative ever had any of the following:
Glaucoma: Y
Asthma: Y
Epilepsy: Y
N Who: ______________________________
N Who: ______________________________
N Who: ______________________________
High Blood Pressure Y
Kidney disease: Y
Diabetes: Y
N Who: ______________________________
N Who: ______________________________
N Who: ______________________________
Tuberculosis: Y
N Who: ______________________________
Psychiatric Disorder Y
Heart disease/stroke Y
N Who: ______________________________
N Who: ______________________________
Past Medical History: (circle all that apply)
Polio
Measles
Tonsillitis
Jaundice
Mumps
Pleurisy
Kidneys
Scarlet Fever
Liver Disease
Lung Disease
Whopping 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, fiancé or partner overweight? Y
By how much is he or she overweight?
9. How often do you eat out?
N
10. What restaurants do you frequent?
11. How often do you eat fast foods?
12. Who plans meals?
Cooks?
Shops?
13. Do you use a shopping list? Y
N
14. What time of the day and what day do you shop for groceries?
15. Food Allergies (list):
16. Food dislikes (list):
17. Foods you crave:
18. Any specific time of the day or month do you crave food?
19. Do you drink coffee or tea? Y
N
20. Do you drink soft drinks? Y
N
21. Do you drink alcohol? Y
N
22. Do you use a sugar substitute? Y
How much daily?
How many daily?
Diet or regular?
How much?
N
23. Do you awaken hungry during the night? Y
N
What do you eat?
Have you ever found evidence of night time eating without your knowledge?____________
24. What are your worst food habits?
Do you binge eat? Y___ N ___ How often? _________________________________________
25. Have you ever induced vomiting or taken laxatives or diuretics for weight loss?
Have you ever been diagnosed with bulimia? Y____ N___
Have you ever been diagnosed with Anorexia Nervosa? Y___ N___
26. Snack Habits: What?
When?
How Much?
27. When you are under a stressful situation at work or family related, do you tend to reach more?
Explain:
28. Do you think 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 pack)
____ You smoke 40 cigarettes per day (2 packs)
30. Typical Breakfast Typical Lunch Typical Dinner
Time eaten: ______________Time eaten:_________________ Time eaten:___________________
Where: _____________________________________________
With whom: _________________________________________
31. Describe your usual energy level:
32. Activity Level: (answer only one)
____ Inactive not regular physical activity with a sit-down job.
____ Light activity no organized physical activity during leisure time.
____ Moderate activity-occasionally involved in activities such as weekend golf, tennis, jogging,
swimming or cycling.
____ Heavy activity consistent lifting, stair climbing heavy construction, etc. or regular
____ Vigorous activity participation in extensive physical exercises for at least 60 minutes per
session 4 times per week.
33. Behavior style: (answer only one)
____ You are always calm and easy going.
____ You are usually calm and easy going.
____ You are sometimes calm with frequent impatience.
____ You are seldom calm and persistently driving for advancement.
____ You are hard-driving and can never relax.
Current Symptoms (please circle if present)
General:
Appetite Increase Appetite Decrease Chills Fatigue Fever Sweats
Eyes
Last check up (Date or how long ago)__________
Blurred vision Double vision Cataracts Eye pain Redness Glaucoma
Y
N
Recent change in vision
Y
N
Ears
Decreased hearing Pain Ringing/Use of hearing device Y
N
Nose
Allergies Congestion Obstruction
Y
N
Throat
Enlarged tonsils Snoring Sore throat trouble swallowing
Y
N
Cardiovascular
Chest pain or pressure, fainting or black out spells / Heart murmur
Palpitations(racing heart or skipped beats) Shortness of breath Trouble lying flat
Swelling in legs or feet
Respiratory (Lungs)
Congestion Cough Rattling or wheezing
Stomach and gastrointestinal Last colonoscopy (year) ______
Bloody stools Cramps Constipation Diarrhea Heartburn or reflux Nausea Pain Vomiting
Muscles, joints, and bones
Arthritis Back pain Joint pain or stiffness (where)______________________________________
Morning stiffness Muscle pain Muscle weakness
Skin
Acne Dry or scaly Itching Lump, nodule, or mole (where)______________ Nail changes
Rash (where)________________
Breast Last mammogram___________
Discharge Lump Pain Rash or redness
Neurologic
Forgetfulness Numbness Weakness
Psychiatric
Anxiety Crying spells Depression Insomnia Panic attacks Rage or temper problems
Suicidal feelings
Hormones (Circle all that applies)
Excessive hunger
Excessive thirst
Decreased libido
Hoarseness
Recent hair growth
Hormones (Female) Last female exam ________
Change in periods Y
N
Blood and circulation
Clotting problems Easy bruising
Allergy and immune
Frequent infection Seasonal allergies
Please describe your general health goals and improvements you with to make:
What kind of dietary approach do you feel is best for you? (Circle one, feel free to leave blank,
we’ll go over
this): ALL FOOD, PARTIAL MEAL REPLACEMENT (USE A MEAL REPLACEMENT
FOR ONE OR MEALS DAILY, OR TOTAL MEAL REPLACEMENT (Very low calorie protein
Sparing fast for quicker weight loss).
Do you feel you will need medication for appetite suppression?
Do you want vitamin B12 shots? (These are not given routinely, but many patients request them)
Y N
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.