Weight Loss Program Patient Information Form Page 4

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WEIGHT LOSS PROTOCOL & CONSENT
I, the undersigned as a client of the medically supervised rapid weight loss program understand that when the
exact protocol is followed, I can expect to achieve satisfactory weight loss expectations. I do not have any
medical conditions that preclude my involvement with a strict diet program and I have a regular primary care
physician. The exact protocol consists of the following criteria:
 Keeping a daily weight log during all phases of the program
 Keeping a daily log of what foods I’ve consumed on my Induction Phase worksheets
 Weekly meetings with my weight management professional.
 Taking my injections consistently once a day during the Phase I and II
 Coming to the office for my weekly M.I.C. injection
 Following the diet as it states in my packet and sticking to the foods on my list.
I understand the above protocol and that there are no guarantees of specific amounts of weight loss and that
individuals successes may vary.
Signature: ________________________________ Date:_________________________
PERSONAL MEDICAL HISTORY
FIBROIDS
Y/N
GALLSTONES
Y/N
CARDIAC DISEASE
Y/N
THYROID DISORDER
Y/N
DIURETICS
Y/N
TYPE 1 DIABETES
Y/N
RHEUMATISM
Y/N
HYPERLIPIDEMIA
Y/N
GOUT
Y/N
HYPERTENSION
Y/N
PEPTIC ULCERS
Y/N
GI PROBLEMS
Y/N
PSORIASIS
Y/N
VARICOSE VEINS
Y/N
HYSTERECTOMY
Y/N
IRREGULAR PERIODS
Y/N
Please explain any additional pertinent medical history:
____________________________________________________________________________________________________________
List all medications being taken [Include vitamins and OTC meds]
____________________________________________________________________________________________________________
EXERCISE HISTORY
CARDIOVASCULAR
Y/N
1-3 days a week
5-7 days a week
HEAVY WEIGHTS
Y/N
1-3 days a week
5-7 days a week
LIGHT WEIGHTS
Y/N
1-3 days a week
5-7 days a week
NONE
Y/N
Have you had and surgical procedures for weight management? Y/N
1. Are you a Vegetarian? Y/N
2. If yes, what type: Please check which one
Vegan (plant only) __ Lactovegetarian (plant and dairy) _____
Ovalactovegetarian (Plant, Dairy and egg) __ Fruitarian (Fruits, nuts, honey, vegetables) __
3. Do you have any food allergies/sensitivities? Y/N ___________________________
Starting Weight_____ Starting Body Fat Comp____ BP _______ Goal Weight ______

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