All fields marked with an asterisk (*) are required.
Date Of Birth* (Y-m-d)
Driver's License #*
DL - State*
DL Expiration Date* (Y-m-d)
How is your weight ditributed?
Central (abdomen, hips, buttocks)
General (all over, carries weight well)
Challenges maintaining weight loss even with exercise?
Wakes refreshed, energized?
Uses caffeine to get going in the morning?
Energy low all day, Fatigue?
Wired at night (night owl, insomnia)?
Energy crash midafternoon (2, 3, 4pm)?
Women: Any Hot flashes, night sweats, insomnia?
Any Low libido, decreased sex drive?
Any Depression, mood swings?
Any Muscle weakness, decreased muscle tone?
High stress (emotional, financial, physical etc)?
Any; Hair loss, feeling cold frequently, constipation?
Married Single Domestic Partnership Divorced Separated Widowed
# of Children
Emergency Contact Name
Do you have any special needs?
How did you hear about us?
Email address (to receive doctor updates on program and for coupons)
What are your health concerns?
What are your goals coming in today?
Who is your primary care provider?
Please list any allergies you may have
Please list any medications you are currently taking
Please list any supplements you are currently taking
Name of the program (such as Weight Watchers, Jenny Craig, LA Weight Loss, etc)
Name of program:
Length of weeks you participated:
Amount of weight lost:
Did you keep the weight off?
Describe your current exercise regimen
Cigarettes Yes No
Coffee Yes No
Cola Yes No
Water Yes No
Alcohol Yes No
Tea Yes No
Rec drugs Yes No
Other Yes No
Rec drugs Quantity
List hospitalizations or surgeries have you had with corresponding dates.
Have you ever been in an auto accident?
List other injuries including falls and other traumas and when they occurred:
Have you been diagnosed with any diseases or disorders and when?
Pregnant or pregnancy plans?
Date of last Pap Smear?
Have you ever had an abnormal Pap smear?
If yes, please explain
Date of last mammogram?
Have you ever had uterine fibroids?
Have you ever had ovarian cysts?
Have you ever had any breast lumps or masses?
Any prior or current diagnosis of cancer?
Any prior or current diagnosis of type I diabetes?
Any prior or current kidney disease?
Any prior or current liver disease?
Any surgery within the last 4 weeks?
Any surgery scheduled in the next 3 months?
Date of most recent full physical exam.
Any abnormalities noted?
Date of most recent blood work.
Weight 1 yr. ago
Fatigue Y N P
Weakness Y N P
Skin Rashes Y N P
Eczema Y N P
Hives Y N P
Acne Y N P
Itching Y N P
Color Change Y N P
Lumps Y N P
Night Sweats Y N P
Headaches Y N P
Head Injury Y N P
Impaired Vision Y N P
Corrected Vision Y N P
Eye Pain Y N P
Tearing/Dryness Y N P
Double Vision Y N P
Glaucoma Y N P
Cataracts Y N P
Constipation Y N P
Liver Disease Y N P
Eye Floaters Y N P
Frequent Colds Y N P
Sinusitis Y N P
Postnasal Drip Y N P
Dizziness Y N P
Nose Bleeds Y N P
Sore Mouth/Gums Y N P
Hoarseness Y N P
Cavities Y N P
Change in Taste Y N P
Goiter Y N P
Neck Pain Y N P
Cough Y N P
Sputum Y N P
Spit up Blood Y N P
Wheezing Y N P
Asthma Y N P
Bronchitis Y N P
Pneumonia Y N P
Pleurisy Y N P
Emphysema Y N P
Difficulty Breathing Y N P
Shortness of Breath Y N P
Tuberculosis Y N P
Heart Disease Y N P
Jaundice Y N P
Indigestion Y N P
Hemorrhoids Y N P
Abdominal Pain Y N P
Anal Discomfort Y N P
Peptic Ulcer Y N P
Kidney Disease Y N P
Frequent Kidney Infection Y N P
Kidney Stones Y N P
Arthritis Y N P
Thrombophlebitis Y N P
Coordination Difficulties Y N P
Speech Difficulties Y N P
Excessive Thirst Y N P
Excessive Hunger Y N P
Blood Sugar Dysregulation Y N P
Anemia Y N P
Easy Bleeding Y N P
Blood Transfusion Y N P
Depression Y N P
Impaired Hearing Y N P
Ear Ringing Y N P
Earaches Y N P
Pain on Urination Y N P
Urinary Frequency Y N P
Inability to Hold Urine Y N P
Gall Bladder Disease Y N P
Blood in Urine Y N P
Joint Pain/Stiffness Y N P
Angina Y N P
High Blood Pressure Y N P
Heart Murmur Y N P
Palpitations Y N P
Edema Y N P
Difficulty Swallowing Y N P
Heartburn Y N P
Change in Thirst/Appetite Y N P
Nausea Y N P
Vomiting Y N P
Diarrhea Y N P
Change in Bowel Movements Y N P
Blood in Stool Y N P
Gas/Bloating Y N P
Broken Bones Y N P
Muscle Spasms Y N P
Deep Leg Pain Y N P
Cold Hands and Feet Y N P
Varicose Veins Y N P
Mood Swings Y N P
Eating Disorder Y N P
Memory Loss Y N P
Drug/Alcohol Abuse Y N P
Difficulty Sleeping Y N P
Phobia Y N P
Blue/Blanched Skin Y N P
Fainting Y N P
Seizures Y N P
Paralysis Y N P
Muscle Weakness Y N P
Numbness/Tingling Y N P
Anxiety Y N P
Thyroid Problem Y N P
Temperature Intolerance Y N P
Age menses ended
Average cycle length
Average bleeding length
Number of pregnancies
Spotting Y N P
Irregular Cycles Y N P
Pain with Intercourse Y N P
Painful Menses Y N P
Birth Control Y N P
Sexual Difficulties Y N P
Breast Lumps Y N P
Breast Pain Y N P
Nipple Discharge Y N P
STD Y N P
PMS Symptoms Y N P
Vaginal Dryness Y N P
Vaginal Discharge/Sores Y N P
Menopausal Symptoms Y N P
Hernias Y N P
Testicular Masses Y N P
Testicular Pain Y N P
Penile Discharge/Sores Y N P
Prostate Disease Y N P
Are there any additional health concerns or questions you have?
hereby authorize the
physician contracted by Perfect Health Technologies / DietDoc to use the following to facilitate my diagnosis and treatment:
Use of nutrition: (Therapeutic nutrition, nutritional supplements and intramuscular vitamin injections)
Botanical medicine:(Teas, alcohol and glycerin extracts, solid extracts, capsules, tablets, creams, ointments and suppositories)
Prescription medications: (Antivirals, Dietdoc, antibiotics, antifungal, hormonal, or other prescription medications)
Physical medicine:(Massage therapy, muscle energy stretching, trigger point release, manipulation, hydrotherapy, or similar hands-on therapies)
Lifestyle counseling and hygiene: (Diet therapy, promotion of wellness including recommendations for exercise, sleep and stress.)
Potential benefits: Restoration of health and the body’s maximum functional capacity without the use of drugs or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.
Potential risks: Allergic reactions to prescribed medications, herbs and supplements, side effects of natural medications, inconvenience of lifestyle changes, injury from injections, venipunctures or procedures, tenderness/soreness or bruising from physical treatments.
Side Effects: The Dietdoc side effects to keep an eye out for include the onset of headaches, irritability, restlessness, slight water retention, tenderness of breast tissue, swelling of the injection site, and depression. There are some rare, severe side effects as well which include the development of ovarian hyper stimulation in females. The latter condition requires immediate medical treatment and is accompanied by the following symptoms: tremendous pain in the region of the pelvis, the swelling of feet, legs, and hands, abdominal pain, abdominal swelling, difficulty breathing, diarrhea, vomiting, nausea, a diminishing of urination, and weight gain. If a user of Dietdoc products notes any side effects it is recommended that he or she cease using the products immediately and that he or she seek out the assistance of a physician.
Notice to all pregnant women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to pregnancy. There are no therapies at Diet Doc that are acceptable for pregnant woman.
I understand that a record will be kept of the health services provided to me. This record will be kept confidential, and will not be released to others unless so directed by myself, my representative, or unless law requires. I understand that I may look at my medical record and can request a copy of my record by my paying the appropriate fee. I understand that my medical record will be kept no more than ten years after the date of my last treatment. I understand that the doctor will answer any questions that I might have.
With this knowledge, I voluntarily consent to the above procedures. I realize that neither the doctor nor any personnel of Perfect Health Technologies / DietDoc has made any absolute guarantees to me regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and discontinue participation in these procedures at any time. I waive my right to future litigation regarding my present health condition by signing this agreement.
I, (patient name) hereby authorize Perfect Health Technologies / Diet Doc Weight Loss to communicate with me via email. ____________(electronically sign).
Print Name *
Signature of Patient Representative or Guardian
I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Perfect Health Technologies/ DietDoc. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.
Perfect Health Technologies / DietDoc reserves the right to change the privacy practices that are describes in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.
In addition to the allowable disclosure described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below. (Please circle)
ANY MEMBER OF THE IMMEDIATE FAMILY Y / N
ANY MEMBER OF THE IMMEDIATE FAMILY
OTHER (please Specify):
Name of Patient or Personal Representative*
Signature of Patient or Personal Representative
Your privacy is very important for us, please let us know the best way to reach you and if we may leave a message during our weekly follow -up calls"
Phone messages okay
Please do not leave messages on either phone
Email only *
Electronically Signed By *
Diet Doc Weight Loss is a unique medically, supervised weight loss program which personalizes a diet for each person. In order to lose the weight desired, it's important that the overall program is followed specifically according to the Diet Doc workbook and weight loss doctor and nurse recommendation. If weight loss ceases or slows down by half, it's necessary to call or email Diet Doc as we are experts at reversing weight loss plateaus. If your weight loss does not continue as anticipated, a daily food journal must be submitted along with discussions (by phone or email) to our weight loss nurse, nutritional coach and/or doctor.
Patient Acknowledges Diet Doc Guarantee: *
If patient is seeking health care reimbursement, Diet Doc Weight Loss will provide documents and receipts for patient to submit to insurance company for reimbursement, but Diet Doc Weight Loss does not make claims or promises that the individuals health insurance will reimburse. This is 100% the patients responsibility.
Patient Acknowledges Health Care Reimbursement: *
How did you hear or learn about our DietDoc™ Program?
Referred by: Please circle one: Friend Family Member Workmate Other
Referred by (name):
Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.
We use and disclose the information we collect from you only as allowed by the Health Insurance Probability and Accountability Act and the state of Washington. This personal health information will never be otherwise given to anyone- even family members- without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose.
We will only request personal information needed to provide our standard of quality care, implement payment activities, conduct normal practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, ECT. Perfect Health Technologies retains full ownership of all documentation collected, and reserves the right to duplicate it for treatment purposes. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental official under certain circumstances. We will not use your information for marketing purposes without your written consent.
We may use and/or disclose your health information to communicate reminders about your appointments including voicemail/answering machine messages, postcards, newsletters and special events.
You have the right to request copies of your healthcare information; to request copies in various formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for used other than stated above. All such requests must be in writing. We may charge you for copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.
We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.
Name of Patient or Personal Representative
How Do you came to know about us ?
Google Yahoo MSN Facebook Twitter Television commercial Radio commercial Magazine article Other
1. I understand that my health care provider wishes me to engage in a telemedicine consultation.
2. I understand how the telemedicine video/phone conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
4. I have had the alternatives to a telemedicine consultation explained to me
My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. By signing this form, I certify: · That I have read or had this form read and/or had this form explained to me · That I fully understand its contents including the risks and benefits of the telemedicine consultation(s). · That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
Electronically signed and acknowledged by:
© Copyright 2015 Diet Doc. All rights reserved.