American Weight Loss Center
Erin Chamberlin- Snyder M.D. FAAFP
Board Certified by
American Board of Obesity Medicine
Welcome to my practice. I’m honored to be your bariatric physician, and I’m committed to providing you
with the best care I can. My hope is that we form a partnership to keep you as healthy as possible, no
matter what your current state of health. I will share my medical expertise with you, and I hope you’ll
take responsibility for working toward the healthy lifestyle that is so important to your well being. Few of
us, myself included, have a completely healthy lifestyle, but each day we can take a step closer to a
healthier life.
It will give me great pleasure to work with you on your weight control goals, either through my own
expertise, through reading I might give you, or by referring you to the nutritionist at American Weight
Loss. I encourage you to keep in contact with your primary care doctor.
We want everyone to be involved in their own health maintenance program. Everyone who joins our
practice will start by having a physical exam followed by periodic check-ups to watch out for problems
and modify your program. We will make you aware of the food and supplement programs available to
achieve maximum success. Additional tests may be recommended and also medications to assist you
will be discussed if you so desire.
We look forward to working with you. Let’s work together to help you live the satisfying life that you
deserve.
Enclosed you will find a Patient Registration, Medical History and Screening Forms. Bring all
completed forms, driver licenses, bottles of all pills you take including over the counter medications,
copies of blood work, EKG (heart test), insurance card and a 3 day food diary, to your appointment
on ________ @______ @______________location . Your cost for your 1st initial office visit
could be_______ and any additional medications or supplements. Because you may be getting an
EKG Please wear NO LOTION on the body. We ask everybody to be courteous to all
patients/staff and refrain from wearing any perfumes/cologne to your appointment.
Sincerely,
Erin Chamberlin- Snyder MD and staff
Locations:
Fishers: 13121 Olio Rd, Suite 100B, Fishers 46037
Franklin: 1101 Professional Blvd Suite S (Johnson Memorial Campus), 46131
Greenwood/Indianapolis: 5145 S. Meridian Street, Suite B, Indianapolis
Anderson: 1537 S Scatterfield, Suite C (White River Complex), 46016
765-644-5673**1888-636-0333**Fax 765-644-4997
Erin Chamberlin-Snyder MD
Patient Registration
Date: ___________ SS #______/______/_____ DL #_________________State____ Exp___/___
Patient’s Name: _____________________
Gender: Male----Female Age: _______________
Address: ___________________________
Marital Status: S M Sep
Div
Wid
City: _______________________________ Date of Birth: ___________________________
State: ________________Zip: __________
Height: ________Present Weight____________
Home Phone(___)___________________
Weight at age 18_________________________
What Phone number may we leave a DETAILED message on?__________________________
Pager: _____________________________
Cell Phone: (____)_______________________
E-Mail Address: ____________________Race: (Optional research ONLY) cac /afr-am/ other________
Patient’s Employment: __________________________________________________________
Address: ________________________________________Phone#: (____)_________________
City: __________________________________________State______________Zip: ________
Spouse, Partner, or Guardian’s Information:
Name: _____________________________
SS#:_______________________________
Emp Phone#:________________________
Pager # :____________________________
Date of Birth:____________________________
Employment:____________________________
Address:_______________________________
Cell Phone #:____________________________
Family Doctor: _______________________ Address: _______________________________
Phone: ____________________________City:_____________State_______________
Insurance Co:________________________________Give Card to front Desk/Driver License
Insurance Cardholder Name:____________________Employment of Cardholder__________________
Date of Birth of Cardholder______________________Relationship to Cardholder__________________
********************************************************************************************
Emergency Numbers:
Name:______________________________ Phone #:_______________________________
(Nearest relative not living with you….Mother..Sister..Aunt..Neighbor..Friend)
How did you hear about our practice: Newspaper---Phone Book---Friend---Physician Referral
Name of Referral: ______________________________________________________________
Office Policy’s
1. Due to the amount of regulations and paperwork involved, Erin Chamberlin-Snyder MD is ONLY signed up
with certain Insurance companies. Office visits, Lab, EKG, Elg, Co-Pay ,Supplements, etc., are due at the time
of services, unless other arrangements have been made.(NO REFUNDS) We will file your 1st insurance as a
courtesy. If you would like your 2nd insurance filed and we are not signed up with that company there will be a
$ 5.00 filing fee each time. We will give your insurance company 30 days to pay your insurance balance.
After that time you will be responsible for the remaining balance and for contacting your insurance
company.
2. All new patients who haven’t had a CBC,TSH, Lipid Panel, CMP, UA and EKG done in the past 12 months
must get those tests done at Dr Chamberlin-Snyder’s office. According to American Society of Obesity
Physicians Practice Guidelines, all test and paper work must be completed and presented before the Physician
can place the patient on a VLCD or medication.
3. We accept Cash, Visa, Master Card, Discover, and Debit Cards.
4. To avoid a $25.00 failure charge, notify our office within 24 hours to cancel your appointment.
5. Prescriptions will not be called into the pharmacy between office visits. To prevent medication error or
substitutes, the Doctor does not refill medications by fax or pharmacy phone calls. Refills must be requested
during your visits. If you have a medication from your primary doctor call their office.
6. All programs and Products are nonrefundable.
7. After reviewing your test results and medical history, we cannot guarantee that the physician will prescribe a
medication or place you on the program you have requested.
8. We are not Medicare/Medicaid providers. I understand that Medicare/Medicaid may not pay for any for any services
rendered by Erin Chamberlin-Snyder MD even if bill Medicare or Medicaid myself. Medicare may cover counseling for
dietary and behavioral changes if your Body Mass index>/= 30. Please inform Physician if you would like a receipt for
our services to submit to Medicare. If Medicare or any insurance companies send you an explanation of benefits please
bring the letter to your next appointment so we can serve you better._______initials
9. I authorize American Weight Loss Center Inc./ Erin Chamberlin-Snyder MD to furnish information to
insurance carriers concerning my treatment and I hereby assign to the physician all payments. I, the
undersigned, am fully aware that my services may be a non-covered service for obesity: therefore, the balance
is my responsibility. In the event of default of payments when due, Erin Chamberlin-Snyder MD, has the right,
but not the obligation, to declare the entire amount to be immediately due. AWL/Erin C. Snyder has the right
to declare an additional $10.00 to the unpaid balance every 30 days. In the event that the balance is not paid
within 90 days your account will be referred to collections. The undersigned agrees to pay all costs of
collections, including but not limited to collection fees, court cost, and reasonable attorney’s fees.
10. If Patient is requesting a copy of MD notes, there is a $ .15 charge per page or $ 15.00 for chart.
11. There is a $ 50.00 charge for letters written to summarize physician supervised treatment for purposes of
bariatric surgical referral or authorization.
12. We no longer call in medications to pharmacies and/or to mail away pharmacies between office visits. Refill
must be requested during your visits. Bring all medications bottles to appointment.
HIPPA:
I consent to American Weight Loss Centers and their physicians to use and disclosure of my Protected Health
Information for the purpose of providing treatment to me, for purposes relating to the payment of services rendered
to me, and for the Practice’s general healthcare operations purposes. Healthcare operations purposes shall include,
but not be limited to, quality assessment activities, credentialing, business management and their general operation
activities, I understand that the Practice’s diagnosis or treatment of me may be conditioned upon my consent as
evidenced by my signature on this document.
I understand I have the right to request a restriction on the use and disclosure of my Protected Health Information
for the purposes of treatment, payment or healthcare operations of the Practice, but the Practice is not required to
agree to these restrictions. However, if the Practice agrees to a restriction that I request, the restriction is binding
on the Practice. I understand I have the right to review and request a copy of the Practice’s Notice of Privacy
Practices prior to signing this document. The Notice of Privacy Practices describes my rights and the Practice’s
duties regarding the types of uses and disclosures of my Protected Health Information. I give AWL/Erin
Chamberlin-Snyder MD permission to call my home, work, cell or mail any information regarding my
appointment or reminders to me or give any information to my immediate family.
I have the right to revoke this consent, in writing, at any time, except to the extent that Physician or the Practice
has acted in reliance on this consent. I further acknowledge that I have received, reviewed, understood and agreed
to the Notice of Privacy Practices of American Weight Loss Centers/ Erin Chamberlin-Snyder MD, which
described the Practice’s policies and procedures regarding the use and disclosure of any of my Protected Health
Information created, received or maintained by the Practice.
________________
__________________________
Date
Signature (Parent or guardian must sign for patients under 18 years old)
_________________
Witness
Medical History Form
PLEASE FILL IN ALL BLANKS/CIRCLE OR PRINT “NONE” IF APPLICABLE.
Date:____________________________
Name:
Age:
Date of Birth______________Sex:
Primary Care Physician:
M
F
Dr. Phone: ________________Height_____
Is it OK to send information to your physician YES or NO
Present Status:
1. Are you in good health at the present time to the best of your knowledge?
2. Are you under a doctor’s care at the present time?
If yes, for what?
3. Are you taking any medications/supplements(over the counter pills) at the present time?
Med. Name
MG
Dosage
Time Taken
Date Started Med.
Yes
Yes
No
No
Yes
For what Problems?
No
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
______________/________/___________/_____________/___________________/_____________________________
______________/________/___________/_____________/___________________/_____________________________
______________/________/___________/_____________/___________________/_____________________________
______________/________/___________/_____________/___________________/_____________________________
______________/________/___________/_____________/___________________/_____________________________
4. Any allergies or sensitive (side effects) to any medications?
Yes
No
Medications: ____________________/__________________ Type of Reaction:__________________/__________________
/ ___________________ /______________
___________________/_____________/__________________
5. Have you ever had a history of High Blood Pressure?
When:______________________
Yes
No
6. Have you ever been told you have High Blood Sugars (Diabetes)? When:______________________
Yes
No
7. Have you ever had heart problems, Heart attack or Chest Pain? Yes
No
If yes when____________________Where________________
8. Have you ever had a stress test on your heart?
Yes
No
If yes when____________________Where________________
9. History of Swelling Feet
Yes
No
If Yes when_____________________
10. History of Headaches?
Yes
No
How Often:___________ Medications_________________
11. Have you ever had Migraines?
Yes
No
Medications for Migraines:
________
12. History of Constipation (difficulty in bowel movements)?
Yes
No
How often do you have bowel movements________________
13. Last Eye Exam?______________ Have you ever had glaucoma? Yes
No
14. Gynecologic History:
Pregnancies: Number:
Dates:
Any High Blood Sugars?
Yes
No
What are you using to prevent pregnancy?__________________________________
15. Other Medical Problems____________________________________________________________________________
_______________________________________________________________________________________________
Yes
No
14. Any Hospitalizations
Yes
Specify: _____________________________________________________________________________ Date: ____________
Specify: _____________________________________________________________________________ Date: ____________
No
15..Any Surgery:
Specify:
Specify:
No
16. History of sleep problems?
________
Yes
No
Have you had a sleep study? Yes
Yes
Date: ____________
Date: ____________
No What was the result?__________________
Reviewed by Physician____________________(initials)
1
NAME:_________________________________________DOB:_____________________________TODAY’S DATE:__________________________
PLEASE FILL IN ALL BLANKS/CIRCLE OR PRINT “NONE” IF APPLICABLE.
Your Past Medical History: (check all that apply)
________ High Blood Sugars
Kidney Disease
________ Chicken Pox
________ Ulcers
________ Heart Disease
________ Drug/Alcohol
________ Pneumonia/Asthma
_____
Chronic pain
write down date of illness
______ Jaundice
_______Chest Pain
_______ Arthritis
______ Scarlet/Rheumatic Fever
_______ Liver Disease
_______ Lung Disease
______ Bleeding Disorder
________ Gout
_______ Osteoporosis
______ Thyroid Disease
Anemia
______ Heart Valve Disorder
______ Tuberculosis
________ Gallbladder Disorder
_______ Blood Transfusion
______ Eating Disorder(anorexia)
________High Chol.
_______ Depression
______ Marijuana Treatment
________ Cancer
What hurts__________________________________Circle level 1 2 3 4 5 6 7 8 9 severe
Family History:
Alive Death
Age of Father:
Age of Mother:
Age of Brothers
Age of Sisters:
At what age did any of your family members have the following:
Stroke Heart
Thyroid
Diabetes Glaucoma Obesity B/P High Chol. Other No Problems
______________________________________
______________
______________
______________
Nutrition Evaluation:
1.
2.
4.
5.
Present Weight:
Height (no shoes):
Desired Weight_______________
In what time frame would you like to be at your desired weight?
Weight at 20 years of age:
Weight one year ago:
What is the main reason for your decision to lose weight?
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:
When/How much did weight did you lose?
What Medications used
Any Side Effects?
___________________
______________
_______________
________________________________
___________________
______________
_____________________________
_________________________________
___________________
______________
8. Who lives in your Home? _____________________________ ages _________________________________
_____________________________ages __________________________________
9. How often do you eat out?
Where?___
When_____________
10. Who plans meals?
Cooks?
Shops? _________
11 Do you use a shopping list?
Yes
No
12. What time of day and on what day do you shop for groceries?
13. Food allergies:
14. Food dislikes:
15. Food you crave:
When?
16. Do you drink coffee or tea?
Yes
No
How much daily?
17. Do you drink soft drinks?
Yes
No
How much daily?
____diet or regular
18. Do you drink alcohol?
Yes
No
What Kind ?__________________________How many a week?__________
19. Do you use a sugar substitute?
Butter? __
_ Margarine?
___ _ Olive Oil? _____________
20. Do you awaken hungry during the night?
Yes
No
What do you do?
22. What are your worst food habits?
23. Snack Habits: What?
How much?
When?
24 When you are under a stressful situation at work or family related do you tend to eat more? Explain:
_______
25. Do you think you are currently undergoing a stressful situation or an emotional upset? Explain:
__
____
Reviewed by Physician____________________(initials)
2
NAME:_________________________________________DOB:_____________________________TODAY’S DATE:________________________
PLEASE FILL IN ALL BLANKS/CIRCLE OR PRINT “NONE” IF APPLICABLE.
26. Are you being physically abused
Yes
No
Sexually abused
Yes
No
Emotionally abused
Yes No
27. In the past have you been Physically abused
Yes
No
Sexually abused
Yes No
Emotionally abused
Yes
No
28. 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 used to smoke ______ packs per day_______for years__________but Quit_________year
You smoke _____Cigarettes per day For _________ years?
29. Have you ever taken Wellbutrin or Zyban?
Yes No
Why?_____________________________________________
30. Describe your usual energy level:
31. Activity Level: (answer only one)
Inactiveno 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 participation
in jogging, swimming, cycling or active sports at least three times per week.
Vigorous activityparticipation in extensive physical exercise for at least 60 minutes per session
4 times per week.
32. Behavior style: (answer only one)
You are always calm and easygoing.
You are sometimes calm with frequent impatience.
____ You are seldom calm and persistently driving for advance
You are never calm and have overwhelming ambition.
33. Please describe your general health goals and improvements you wish to make:___________________________________________
__________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
34. Typical Breakfast
Time eaten:
Where:
With whom:
Typical Lunch
Typical Dinner
Time eaten:
Where:
With whom:
Time eaten:
Where:
With whom:
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.
Reviewed by Physician____________________(initials)
Screening of Depression/Beck Inventory
Name_____________________DOB___________
Date ___________________________________
On this questionnaire are groups of statements. Please read
each group carefully. Then pick out the one
statement in each group that best describes the way you have
been feeling the past week including today. Circle the
number beside the statement you picked. If several statements
in the group seem to apply equally well, circle each one. Be
sure to read all the statements in each group before making
your choice.
1.
0 I do not feel sad.
1 I feel sad.
2 I am sad all the time and can't snap out of it.
3 I am so sad or unhappy that I can't stand it.
2.
0 I am not particularly discouraged about the future.
1 I feel discouraged about the future.
2 I feel I have nothing to look forward to.
3 I feel that the future is hopeless and that
things cannot improve.
3.
0 I do not feel like a failure.
1 I feel I have failed more than the average person.
2 As I look back on my life, all I can see are a lot of failures.
3 I feel I am a complete failure as a person.
4.
0 I get as much satisfaction out of things as I used to.
1 I don't enjoy things the way I used to.
2 I don't get real satisfaction out of anything anymore.
3 I am dissatisfied and bored with everything.
5.
0 I don't feel particularly guilty.
1 I feel guilty a good part of the time.
2 I feel quite guilty most of the time.
3 I feel guilty all of the time.
6.
0 I don't feel I am being punished.
1 I feel I may be punished.
2 I expect to be punished.
3 I feel I am being punished.
7.
0 I don't feel disappointed in myself.
1 I am disappointed in myself.
2 I am disgusted with myself.
3 I hate myself.
8.
0 I have not lost interest in other people.
1 I am less interested in other people than I used to be.
2 I have lost most of my interest in other people.
3 I have lost all of my interest in other people.
9.
0 I make decisions about as well as I ever could.
1 I put off making decisions more than I used to.
.2 I have greater difficulty in making decisions than before.
3. I can't make decisions at all anymore.
10.
0 I don't feel I look worse than I used to.
1 I am worried that I am looking old or unattractive.
2 I feel that there are permanent changes in my
appearance that make me look unattractive.
3 I believe that I look ugly.
11.
0 I can work about as well as before.
1 It takes an extra effort to get started to do something.
2 I have to push myself very hard to do anything.
3 I can’t do any work at all.
12.
0 I can sleep as well as usual.
1 I don’t sleep as well as I used to.
2 I wake up 1-2 hours earlier than usual/can’t get back to
sleep.
13.
0 I don’t get tired more than usual.
1 I get tired more than usual.
2 I get tired from doing almost anything.
3 I am too tired to do anything.
14.
0 My appetite is no worse than usual.
1 My appetite is not as good as it used to be.
2 My appetite is much worse now.
3 I have no appetite as all anymore.
15.
0 I don’t feel I am any worse than anybody else.
1 I am critical of myself.
2 I blame myself all the time for my faults.
3 I blame myself for everything bad that happens.
16.
0 I don’t have any thoughts of killing myself.
1 I have thoughts of killing myself, but would not carry them out.
2 I would like to kill myself
3 I would kill myself if had the chance.
17.
0 I am no more worried about my health then usual.
1 I am worried about physical problems such as aches and pains
or upset stomach and constipation.
2 I am very worried about physical problems, and it is hard to
Think of much else.
3 I am so worried about my physical problems that I cannot
Think of anything else.
18.
0 I don’t cry any more than usual.
1 I cry more now than I used to.
2 I cry all the time now.
3 I used to be able to cry, but now I can’t cry even though I
want to.
19.
0 I have not noticed any recent change in my interest in sex.
1 I am less interested in sex than I used to be.
2 I am much less interested in sex now.
3 I have lost interest in sex completely.
20.
0 I am no more irritated now than I ever was before.
1 I get annoyed or irritated more easily than I used to.
2 I feel irritated all the time now.
3 I don’t get irritated at all by the things that used to irritate me.
.
Reviewed by Physician____________________(initials)
Weight Loss Program Consent Form
I ______________________________________ authorize Erin Chamberlin-Snyder MD and whomever is
designate as their assistants, to help me in my weight reduction efforts. 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. 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 duration’s 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 not 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:
(Or person with authority to consent for patient)
12 Reasons
“Why I want to Reach My Goal Weight”
Name___________________________Date_____________________
It is important that these 12 reasons be true personal goals and desires. They should not be
generalizations or what you think would please others because they will be used as your
“personal motivator.” Try to make them specific, measurable, and time related. (IE I want to be
able to walk 5 blocks without being short of breath by June 2008)
1.___________________________________________________________________________
2.___________________________________________________________________________
3.___________________________________________________________________________
4.___________________________________________________________________________
5.___________________________________________________________________________
6.___________________________________________________________________________
7.__________________________________________________________________________
8.__________________________________________________________________________
9.__________________________________________________________________________
10._________________________________________________________________________
11._________________________________________________________________________
12._________________________________________________________________________
Anderson/Fishers/Franklin/Greenwood
765-644-5673/1-888-636-0333