Initial Bariatric Assessment - New Patient Forms

Initial Bariatric Assessment - New Patient Forms
PLEASE NOTE THIS FORM MAY NOT LET YOU SIGN IN MOBILE VERSION ON A CELL PHONE- YOU MAY NEED TO VIEW IN DESKTOP VERSION ON YOUR PHONE OR USE LAPTOP TABLET OR PC

Thank you for scheduling your first visit in our medical weight loss program! We are so excited you have taken this step and started your journey in weight loss!

This visit is for your Initial Bariatric Assessment and will include 2 tests followed by a visit with the bariatrician or ARNP to discuss results. The tests are called a Dexa (body composition analysis scan) and a ReeVue (breathing test that determines resting metablic rate).

There are some instructions for the tests that are included below. Please review and call us if you have any questions at all.

Please check-in 15 minutes prior to your scheduled appointment time with your insurance card and ID. If you arrive late for your check-in time you may be asked to reschedule.

Please bring with you:

· Your picture ID

· Current Insurance Card

· Payment for IBA that was discussed at MWL Consult (that amount is listed on the Overview of the Medical Weight loss program sheet)

Note: We only accept debit/credit cards or check. We unfortunately are unable to accept cash, we apologize for this inconvenience.

If you are unable to keep your appointment, please call us at 253-268-3345

Sincerely,

HorizonView Health Staff
Preparing for Diagnostic Appoinmtents (IBA)

ReeVue: Resting Metabolic Rate

This is a simple breathing test that lasts approximately 10 minutes. It calculates the number of calories your body burns while at rest and is useful for determining a safe and sustainable calorie deficit that will promote weight loss.

Instructions to prepare for test:
- Do not eat or drink anything, except water, for atleast 4 hours prior to test.
- No exercise for at least 4 hours prior to appoinmtent
- Do not consume caffeine or supplements for at least 4 hours prior to appointment
- Continue taking your regular prescription medications.
Note: Discontinue any appetite suppressant medications 2 days prior to your appointment

DXA Scanner: Body Composition Analysis

The DXA Scanner is a state-of-the-art diagnostic test used by many professional athletes to monitor lean muscle mass. Patients lie on a flat surface for a few minutes while a computer scans the body and calculates the percentage of fat, lean muscle, water, and other body tissues. This is an essential test to ensure fat and not muscle is being lost during the reducing phase.

Instructions to prepare for this test:
- Remove all metal jewlery and accessories
- No metal on or in clothing including zippers and underwire bras
- We recommend sweatpants, t-shirts and sports bras for women
Patient Registration

Note: This form is HIPAA compliant and secure
Legal Patient Name*

First NameLast Name
SSN*
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.
Alternative Phone
Please enter a valid phone number.
Email
example@example.com
SSN
Legal Gender*

MaleFemale
Marital Status*

MarriedSingleDivorcedSignificant OtherWidowed
Patient Race*
Ie. Caucasian, Black or African American, Pacific Islander, Chinese, Filipino ect.
Hispanic Ethnicity:*

No - Non HispanicYes - HispanicDecline to answer
Primary Physician (if not establishing care with HorizonView Health)
Patient Employment
Employment Status*

EmployedRetiredOther
Employer
Occupation/Title
Responsible Party (If patient age 17 or younger)
Legal Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Employer
Primary Insurance
Insurance Name/Type*
Subscriber Legal Name*

First NameLast Name
Subscriber Phone*
Please enter a valid phone number.
Subscriber DOB*

MonthDayYear
Date
Subscriber Employer
Relationship to Patient*
ID Number*
Group Number
Secondary Insurance (if applicable)
Insurance Name/Type
Subscriber Legal Name

First NameLast Name
Subscriber Phone
Please enter a valid phone number.
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Employer
Relationship to Patient
ID Number
Group Number
Emergency Contacts
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Notify on Hospital Admission?*

YesNo
Secondary Emergency contact (if applicable)
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Notify on Hospital Admission?

YesNo
Patient Medical Health Profile
Patient Legal Name

First NameLast Name
Spouse's Name or Parent's Name (if minor)
Doctors that you regularly consult: (optional)
Name: Type a label Reason: blank Phone: Area Code Phone Number
Name: Type a label Reason: Type a label Phone: Area Code Phone Number
Medications

Please bring your medicine with you if this is easier
Name:   Type a label   Strength: blank Dose:   Type a label
Name:   Type a label    Strength:   Type a label   Dose:   Type a label
Name:   Type a label   Strength:   Type a label   Dose:   Type a label
Name:   Type a label   Strength:   Type a label   Dose:   Type a label
Name:   Type a label   Strength:   Type a label   Dose:   Type a label
Name:   Type a label   Strength:   Type a label   Dose:   Type a label
Allergies*
Preferred Pharmacy and Location*
Social History
Marital Status*

MarriedSingleDivorcedWidowedSignificant Other
Do you have children? If so, Please list birth year, sex and health problems: blanks
Type a label
Type a label
Type a label
Occupation*
Employment Status*

Full TimePart TimeRetired
Do you Exercise?*
Amount per week*
Type of Exercise
Smoking?*

Current Every DayCurrent Some DaysFormer/Year QuitNever
Amount Per day
If Former was selected, year quit?
Alcohol*

NeverOccasionalModeratelyDailyFormer
Amount Per Day/Week
If Former was selected, year quit?
Illicit Drug Usage No Yes
If Yes, Type/Frequency blanks
Previously, but quit. Year? blank
THC Usage: Y* No Yes
If Yes, Type/Frequency blanks
Previously, but quit. Year? blank
Past Medical History
Past Surgeries & Approximate Date
Past Hospitalization & Approximate Date
Major Medical Problems
Immunizations:
Tetanus (Last Given) blanks
Pneumonia Shot blank
Shingles Vaccine   Type a label
If Over Age 50: Last Colonoscopy   Type a label
Males Only: Last PSA Test   Type a label
Females Only:
Last Mammogram blanks Normal or Abnormal?
Age of first Menstrual Period: Date of Last Period: Number of Pregnancies: Miscarriages: Birth Control: Type: Type a label

Family History (Please indicate which family member has the health problem)

	Mother	Father	Sister	Brother	Mom's mom	Mom's dad	Dad's dad	Dad's mom
High Blood Pressure
High Cholesterol
Coronary Heart Disease
Diabetes
Breast Cancer
Colon Cancer
Prostate Cancer
Alcoholism
Mental Illness

Father: Alive/Birth Year blanks Passed/Year   Type a label Medical Problems   Type a label
Mother: Alive/Birth Year   Type a label Passed/Year   Type a label
Medical Problems   Type a label
Brother: How many?   Type a label   Medical Problems   Type a label
Sisters: How many?   Type a label   Medical Problems   Type a label

Please select any of the following conditions that you have or have had in the past:

	Current Condition	Past Condition
Weight Loss/Weight Gain
Anxiety
Headaches
Depression
Seizures
Stroke
Tingling location
Tremors
Memory Loss
Fainting Spells/ Dizziness
Head Injury
Localized weakness/ Numbness
Hay Fever
Allergies
Hoarseness
Double Vision
Eye Problems
Ear Infections
Glasses/ Contacts
Hearing Loss
Frequent Nose bleeds
Ringing in ears
Sinus Infections
Swollen Glands
Chest Pain
Heart Murmurs
Leg cramps while walking
Ankle Swelling
Awakening at night short of breath
Cold hands/ feet
Heart attacks
Heart Failure
High/Low blood pressure
Irregular heart rate
Palpitations
Varicose Veins
Wheezing
Asthma
Prolonged Cough
Cough with Excercise
Emphysema/ COPD
Shortness of breath
Pneumonia
Bronchitis
Acne
Hives
Dry Skin
Rashes
Psoriasis
Lumps
Nail Problems
Moles - Irregular
Moles - Changed or New
Skin Tags
Problems Urinating
Dribbling after Urination
Painful Urination
Excessive Thirst
Involuntary Urination/ Incontinence
Weak Flow
Urinating frequently day/ night
Kidney Disease
Frequent Bladder Infections
Painful Intercourse
Sexually Transmitted Diseases
Diabetes
Abnormal Body hair
Cold Intolerance
Heat Intolerance
Increased Hair Loss
Thyroid Disease
Joint pain/ swelling
Muscle Weakness
Morning Stiffness
Constipation
Diarrhea
Gallstones
Heartburn day/ night
Problems Swallowing
Hemorrhoids
Blood in stool

Males Only: Please select any of the following current or past conditions

	Current Condition	Past Condition
Hernia
Penile Discharge
Lump on Testicle
Unable to complete intercourse
Problems Maintaining erection
Prostate Disease
Decreased Urine Stream

Females Only: Please select any of the following current or past conditions

	Current Condition	Past Condition
Hot Flashes
D & C
Bleeding between cycles
Abnormal Pap Smears
Bleeding after intercourse
PMS
Heavy Bleeding during cycles
Discharge from Breasts
Pelvic Inflammatory Disease
Vaginal Discharge
Vaginal Dryness

Medical Forms
Please select any of the following forms you have completed and wish to bring copies to our office to have on record (if any selected please bring copy to appointment)

Advance Directive for Health Care (ADHC)Durable Power of Attorney (DPA) for healthcare decisionsLiving WillPOLST (Physician's orders for Life-Sustaining Therapy)
Authorization to Request Protected Health Information
Please fill out this release so we can request records from any previous medical provider and facilities. You can select "Last Chart Notes, labs, physical/PAP/Mammogram, imaging, EKG, and immunizations" to give us access to your general health information.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
PCP Name: blanksPhone: blank Fax: Type a label
Additional Provider Name: Type a label Phone: Type a label Fax: Type a label
Medical Weight Loss Consent
I, First Name* Last Name* , authorize the Bariatricians at HorizonView Health and their associates to help me in my weight loss 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 bariatric medications. 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.

I understand that my 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 sleeplessness, headaches, dry mouth, gastrointestinal disturbances, weakness, tiredness, high blood pressure, and rapid heartbeat. These and other possible risks could, on rare occasion, be serious in nature. Risks associated with remaining overweight are tendencies to high blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, feet and back, sleep apnea, and sudden fatality. I understand that these risks may be modest if i am not significantly overweight, but the risks 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 is a chronic life-long condition that requires changes in eating habits and permanent changes in behavior in order to be treated successfully.

I have read and fully understand this consent form and my questions have been answered to my complete satisfaction.
Signature*

Clear
Patient Legal Name*

First NameLast Name
Date*

MonthDayYear
Date
Nutrition Questionnaire

Please answer the following questions to the best of your ability, to assist us in determining the best treatment options for you.
1. Are you currently taking any dietary vitamins or supplements? If YES, please provide the vitamin/supplement, amount and dosage (i.e. Nature Made Iron 65mg, 2x/ day
2. Do you have any food allergies or food intolerances?
3. Do you have any religious or cultural food preferences?
4. Are you currently following a specific diet (i.e. Atkins, Keto, gluten-free, ect.) or have a dietary preference (i.e. vegetarian)
5. Do you have any gastrointestinal issues? If YES, when did it start and how often? (i.e. constipation, bloating, IBS, Crohn's disease, delayed gastric motility, ect.)
6. Do you have any current or previous nutritional deficiencies? (i.e. iron deficiency anemia, vitamin D deficiency, ect.)
7. Do you have a previous history or current eating disorders/ behaviors? If YES, please circle all that apply. Indicate how long and if you have received treatment below

AnorexiaBulimiaBingingPurgingOrthorexiaOther (describe below)N/A
If YES to any of the above disorders please indicate which one, for how long and if you have received treatment:
8. Do you eat for any of the following reasons? If YES, please indicate how often below

StressEmotionalBoredomComfortRewardWake up to eatN/A
If YES to any of the above, please indicate how often:
9. What has been the most helpful in previous diets? What do you feel you need for successful weight management?
My Personal Weight Journey
Please Take a moment to answer the following questions about your weight, motivations, and challenges to help guide conversations with your health care professional about a weight-management plan that fits your lifestyle.
Personal Information
Weight: blanks* (lbs) Height: blank* (ft/in)
What do you feel your weight may be holding you back from doing?*
Approximately how much weight would you like to lose to help you reach your goals? blank* (lbs)
Weight-Related Conditions

Select which of the following conditions or diseases you have. Write in any prescription or over-the-counter products you are currently taking.

	Yes	OTC Medications being taken
Sleep Disorders (e.g. sleep apnea, insomnia)
Chronic Pain Conditions (e.g. arthritis)
Cardiovascular Disease
Respiratory Disease
Gastrointestinal Disorders (e.g. liver problems)
Endocrine Disorders (e.g. Hormone)
Diabetes or prediabetes
Depression
Other: (please describe)

Life MIlestones/Events & Weight

In the space provided, share any life events that relate to your weight loss or weight gain. Add any specifics you would like. (Possible life events may include: Special Occasions/events (eg. wedding, baby, class reunion, vacation) Home or work changes (eg. job change, divorce, personal loss, move) Health or medical changes (eg. nutritionist, injury, surgery, medication)

	When did this occur? (age)	Event	How much weight did you lose/gain?	What did you do to lose weight?	Would you do it again? (Y/N)
1.
2.
3.
4.

Weight-Loss/Management Efforts

How would you describe your efforts to lose or maintain weight? Please select all that apply.

	Tried it in the past	Doing it Now
Physical Activity
Healthy Eating
Over-the-counter products
Prescription Medication
Commercial Weight-loss programs (e.g. weight watchers)
Bariatric Surgery

How long have you been trying to lose weight?

Less than 2 years2-4 years5-9 yearsAs long as I can remember
Current Eating & Activity Routines
How would you describe your eating habits? Please select all that apply

Eat 3 meals a dayEat more than 3 meals a dayFrequent SnackerHealthy EaterBinge EaterEmotional EaterConstant DieterOther:
What approaches to healthy eating have you tried in the past? Select all that apply?

Limiting my portion size (e.g. using a smaller plate)Cooking meals at homeUsing meal replacementsAvoiding sugary foods and drinksTracking activity and caloriesReading food labelsOther:
Approximately, how many minutes total per week do you spend doing physical activities such as going for a walk, cleaning the house, climbing stairs, light yard work, or biking?

60 mins or less (1 hour)60-120 mins (1-2 hours)120-180 mins (2-3 hoursMore than 180 mins (3 hours)N/A
Any other weight-related information your health care professional should know?
Mental Health Questionnaire

How often have you ben bothered by any of the following problems:*

	Not at all	Several Days	Over half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling/staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure, or let yourself or your family down
7. Concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking slowly that others have noticed. Or the opposite, restless/fidgety more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult

How often have you been bothered by any of the following problems?*

	Not at all	Several days	Over half the days	Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worry
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Adverse Childhood Experience (ACE) Questionaire

While you were growing up, during your first 18 years of life:*

	Yes	No
1. Did a parent or other adult in your house often swear at you, insult you, put you down, or humiliate you? OR Act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in your house often push, grab, slap or throw something at you? OR Ever hit you so hard that you had marks, bruises, or were injured?
3. Did any adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? OR Did anyone attempt to have oral, anal or vaginal intercourse with you?
4. Did you often feel like no one in your family loved you or thought you were important or special? OR Did you feel like your family members didn't look out for each other, didn't feel close to each other, and didn't support each other?
5. Did you often feel like you didn't have enough to eat, had to wear dirty clothes, or had no one to protect you? OR Were your parents ever too drunk or high to take care of you or take you to the doctor if you needed to go?
6. Were your parents ever separated or divorced?
7. Was your mother or step-mother often pushed, grabbed, slapped, or had something thrown at her? OR Sometimes, often or very often kicked, bitten hit with a fist, or hit with something hard? OR Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinker or alcoholic or used drugs on a regular basis?
9. Was anyone in your household depressed, mentally ill, or ever talked about or tried to commit suicide?
10. Did anyone in your household ever go to prison?

Consent to Treat
CONSENT: I consent to medical services discussed and ordered by a physician and given by HorizonView Health. HorizonView Health may share health information about me, my guardian(s) or parent(s) to physicians and providers who treat me.

FINANCIAL AGREEMENT: I, the patient or guarantor, certify that the information provided is true to the best of my knowledge. I accept responsibility for the medical charges incurred by the patient and agree to pay all bills at the time of service unless arrangements are made. I authorize HorizonView Health, to release any information to process insurance claims. I also authorize my insurance claim to be paid directly to HorizonView Health.

RELEASE OF INFORMATION: I permit HorizonView Health to release information needed for eligibility and benefits, and to process claims for payments. I agree that all insurance payments be paid directly to HorizonView Health for services rendered.

By my signature below, I agree to the Consent of Treatment & have received the Notice of Privacy Practices of HorizonView Health.
Signature*

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Date*

MonthDayYear
Date
Notice of Privacy Practices Acknowledgement
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and Privacy Practices with respect to PHI. We are required to abide by the terms of the Notice of Privacy Practices. We reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices upon request.
Signature*

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Date*

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NO SHOW/MISSED APPOINTMENT POLICY
We, at HorizonView Health, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible. We require at least 24-hour notice when canceling your scheduled appointment. You can cancel appointments by calling us at 253-268-3345.

To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, an appointment reminder call is attempted two (2) business days prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time.

Please review the following policy:

1. Please cancel your appointment with at least 24 hours' notice so your appointment time can be
offered to other patients.
2. If less than 24-hour notice is given, this will be documented as a late cancellation.
3. If you do not show up to your scheduled appointment, this will be documented as a no show.
4. Behavioral Health patients will be charged a $75 fee per no show/late cancellation.

5. All other patients will be charged a $40 fee per no show/late cancellation.
6. If you have three (3) or more no shows/late cancellations, a warning letter will be sent.

7. Patients with continuous no shows/late cancellations will be discharged from HorizonView Health at our discretion.

I have read and understand HorizonView Health's no show/late cancellation policy and understand my responsibility to plan appointments accordingly and notify HorizonView Health appropriately if I have difficulty keeping my scheduled appointments.
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Date*

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Date
THERAPY LATE CANCELLATION AND NO-SHOW POLICY
This policy has been established to provide the highest level of counseling service to all our clients. It has been proven that consistent attendance provides for the greatest opportunity for success.

By providing us with enough notice of cancellation, we may be able to accommodate other clients with your appointment time. Please provide our office with a 24-hour notice to change or cancel an appointment.

Clients who do not provide a 24-hour notice to cancel or change a scheduled appointment will be responsible for a $75.00 late cancellation fee. This charge cannot be billed to insurance.

Clients that do not contact us and do not attend their scheduled appointments are considered no shows. A $75.00 no show fee will be charged. This charge cannot be billed to insurance. If you do no-show, the $75.00 will automatically be charged to the credit card on file.

When late cancellations and/or no shows become excessive, the therapist then has the right to terminate the relationship. Two no shows and/or late cancellations over the year would be considered excessive. This policy is effective January 1st, 2021. We do understand that emergencies arise and that it may not be possible to give such a notice. Exceptions to the late cancellation and no-show policy with be determined by our office.

I have read and understand this policy.
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Telehealth Consent Form
A Telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment (Zoom). This consent is valid for all follow-up Telehealth services with HorizonView Health.

I understand that:

I can decline the Telehealth service at any time without affecting my right to future care or treatment.
If I decline the Telehealth services, the alternative option would be in-person services.
The same confidentiality protections that apply to my other medical care also apply to the Telehealth services.
I will have access to all medical information resulting from the Telehealth service as provided by law.
The information from the Telehealth service (images that can be identified as mine or other medical information from the Telehealth service) cannot be released to researchers or anyone else without my additional written consent. I understand that my insurance will be billed for the telehealth services, and that I will be billed for what my insurance does not cover.
By signing this consent, I am giving permission to release information to my insurance company or third-party payor for billing purposes.
I have read this document carefully, and my questions have been answered to my satisfaction.
I understand this consent is valiid for all telehealth follow-ups at HorizonView Health.
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Date*

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Should be Empty:

Initial Bariatric Assessment - New Patient Forms

Patient Registration

Patient Employment

Responsible Party (If patient age 17 or younger)

Primary Insurance

Secondary Insurance (if applicable)

Emergency Contacts

Secondary Emergency contact (if applicable)

Patient Medical Health Profile

Medications

Social History

Past Medical History

Medical Forms

Authorization to Request Protected Health Information

Medical Weight Loss Consent

Nutrition Questionnaire

My Personal Weight Journey

Personal Information

Weight-Related Conditions

Life MIlestones/Events & Weight

Weight-Loss/Management Efforts

Current Eating & Activity Routines

Mental Health Questionnaire

Adverse Childhood Experience (ACE) Questionaire

Consent to Treat

Notice of Privacy Practices Acknowledgement

NO SHOW/MISSED APPOINTMENT POLICY

THERAPY LATE CANCELLATION AND NO-SHOW POLICY

Telehealth Consent Form