American Weight Loss Center



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: _____________________________ Date of Birth:____________________________

SS#:_______________________________ Employment:____________________________

Emp Phone#:________________________ Address:_______________________________

Pager # :____________________________ 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: M F

Primary Care Physician: 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? Yes No

2. Are you under a doctor’s care at the present time? Yes No

If yes, for what?

3. Are you taking any medications/supplements(over the counter pills) at the present time? Yes No

Med. Name MG Dosage Time Taken Date Started Med. For what Problems?

/ / / / /

/ / / / /

/ / / / /

______________/________/___________/_____________/___________________/___________________________________________/________/___________/_____________/___________________/___________________________________________/________/___________/_____________/___________________/_____________________________ ______________/________/___________/_____________/___________________/___________________________________________/________/___________/_____________/___________________/_____________________________

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 No

Specify: _____________________________________________________________________________ Date: ____________

Specify: _____________________________________________________________________________ Date: ____________

15..Any Surgery: Yes No

Specify: Date: ____________

Specify: ________ Date: ____________

16. History of sleep problems? Yes No Have you had a sleep study? Yes 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) write down date of illness

________ High Blood Sugars ______ Jaundice _______Chest Pain _______ Arthritis

Kidney Disease ______ Scarlet/Rheumatic Fever _______ Liver Disease _______ Lung Disease

________ Chicken Pox ______ Bleeding Disorder ________ Gout _______ Osteoporosis

________ Ulcers ______ Thyroid Disease Anemia ______ Heart Valve Disorder ________ Heart Disease ______ Tuberculosis ________ Gallbladder Disorder _______ Blood Transfusion

________ Drug/Alcohol ______ Eating Disorder(anorexia) ________High Chol. _______ Depression

________ Pneumonia/Asthma ______ Marijuana Treatment ________ Cancer

_____ Chronic pain What hurts__________________________________Circle level 1 2 3 4 5 6 7 8 9 severe

Family History:

At what age did any of your family members have the following:

Alive Death Stroke Heart Thyroid Diabetes Glaucoma Obesity B/P High Chol. Other No Problems

Age of Father: ______________________________________

Age of Mother: ______________

Age of Brothers ______________

Age of Sisters: ______________

Nutrition Evaluation:

1. Present Weight: Height (no shoes): Desired Weight_______________

2. In what time frame would you like to be at your desired 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: 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 Typical Lunch Typical Dinner

Time eaten: Time eaten: Time eaten:

Where: Where: Where:

With whom: With whom: 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

11.

Name_____________________DOB___________ 0 I can work about as well as before.

Date ___________________________________ 1 It takes an extra effort to get started to do something.

2 I have to push myself very hard to do anything.

On this questionnaire are groups of statements. Please read 3 I can’t do any work at all.

each group carefully. Then pick out the one 12.

statement in each group that best describes the way you have 0 I can sleep as well as usual.

been feeling the past week including today. Circle the 1 I don’t sleep as well as I used to.

number beside the statement you picked. If several statements 2 I wake up 1-2 hours earlier than usual/can’t get back to

in the group seem to apply equally well, circle each one. Be sleep.

sure to read all the statements in each group before making 13.

your choice. 0 I don’t get tired more than usual.

1. 1 I get tired more than usual.

0 I do not feel sad. 2 I get tired from doing almost anything.

1 I feel sad. 3 I am too tired to do anything.

2 I am sad all the time and can't snap out of it. 14.

3 I am so sad or unhappy that I can't stand it. 0 My appetite is no worse than usual.

2. 1 My appetite is not as good as it used to be.

0 I am not particularly discouraged about the future. 2 My appetite is much worse now.

1 I feel discouraged about the future. 3 I have no appetite as all anymore.

2 I feel I have nothing to look forward to. 15.

3 I feel that the future is hopeless and that 0 I don’t feel I am any worse than anybody else.

things cannot improve. 1 I am critical of myself.

3. 2 I blame myself all the time for my faults.

0 I do not feel like a failure. 3 I blame myself for everything bad that happens.

1 I feel I have failed more than the average person. 16.

2 As I look back on my life, all I can see are a lot of failures. 0 I don’t have any thoughts of killing myself.

3 I feel I am a complete failure as a person. 1 I have thoughts of killing myself, but would not carry them out.

4. 2 I would like to kill myself

0 I get as much satisfaction out of things as I used to. 3 I would kill myself if had the chance.

1 I don't enjoy things the way I used to. 17.

2 I don't get real satisfaction out of anything anymore. 0 I am no more worried about my health then usual.

3 I am dissatisfied and bored with everything. 1 I am worried about physical problems such as aches and pains

5. or upset stomach and constipation.

0 I don't feel particularly guilty. 2 I am very worried about physical problems, and it is hard to

1 I feel guilty a good part of the time. Think of much else.

2 I feel quite guilty most of the time. 3 I am so worried about my physical problems that I cannot

3 I feel guilty all of the time. Think of anything else.

6. 18.

0 I don't feel I am being punished. 0 I don’t cry any more than usual.

1 I feel I may be punished. 1 I cry more now than I used to.

2 I expect to be punished. 2 I cry all the time now.

3 I feel I am being punished. 3 I used to be able to cry, but now I can’t cry even though I

7. want to.

0 I don't feel disappointed in myself. 19.

1 I am disappointed in myself. 0 I have not noticed any recent change in my interest in sex.

2 I am disgusted with myself. 1 I am less interested in sex than I used to be.

3 I hate myself. 2 I am much less interested in sex now.

8. 3 I have lost interest in sex completely.

0 I have not lost interest in other people. 20.

1 I am less interested in other people than I used to be. 0 I am no more irritated now than I ever was before.

2 I have lost most of my interest in other people. 1 I get annoyed or irritated more easily than I used to.

3 I have lost all of my interest in other people. 2 I feel irritated all the time now.

9. 3 I don’t get irritated at all by the things that used to irritate me.

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. 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

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download