If yes, you are not eligible to participate in this program)
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1 Patient Name: Date: Address: City: St: Zip: Address: Ok to send Yes No Phone: Date Of Birth: How did you find out about our weight loss program? Are you currently pregnant, breast feeding, have active cancer, or cholecystitis? Yes No (If yes, you are not eligible to participate in this program) Do you experience any of the following conditions even if they are minor and go away on their own? High Blood Pressure Diabetes Headaches Hypoglycemia Cancer Neck Pain Upper Back Pain Thyroid Problems Heart Disease Digestive Problems Arthritis Chronic Fatigue Fibromyalgia Numbness Stress/Irritability Sinus/Allergy Hip/Knee Pain Osteoporosis Chronic Inflammation Other 1. Are you currently on any medications and for what health condition? 2. Why do you currently want to lose weight? 3. How long have you struggled with your weight? 4. Have you tried other weight loss plans and if so, what have you tried? 5. What were your results? 6. How long did you keep the weight off? 7. Do you currently take nutritional supplementation? (if yes is the patient taking EFA s? They will need to discontinue EFA s while on this program) 8. Do you have any other health challenges that you feel is important for us to know about?
2 CHIROTHIN WEIGHT LOSS PROGRAM INFORMED CONSENT AND RELEASE OF LIABILITY I understand that my use and consumption of any ChiroThin product or engaging in any weight loss program including the type that is to be used in conjunction with ChiroThin, have inherent risks to my health and well- being, including but not limited to headaches, nausea, dizziness, vomiting, fatigue, pain, loss of consciousness, shortness of breath and other ailments. I understand as well that rapid weight loss of over 1-2 lbs. per week is considered by most in the weight loss medical community to be excessive and may lead to ailments similar and in addition to those mentioned above. Therefore, I understand that my failure to follow the weight loss program exactly as described to me by my physician or chiropractor can result in severe temporary and/or permanent medical conditions in addition to those mentioned above. I understand that I am not to use or consume any of the ChiroThin products if I am pregnant or think I might be pregnant. I understand that, as a dietary supplement, ChiroThin has not been approved by the FDA or any Federal or State authority. I additionally understand that The ChiroThin Weight Loss Program is not meant to diagnose, treat or cure any disease or medical condition and that I am to undergo participation in the ChiroThin Weight Loss Program only under doctor supervision. I also understand that I should consult with my doctor prior to starting ANY exercise or nutritional supplement program. I understand that, if I experience any ailment, including but not limited to headaches, nausea, dizziness, vomiting, fatigue, pain, loss of consciousness, shortness of breath and other ailments, I should immediately stop using or consuming the ChiroThin product and, if my symptoms do not resolve immediately, I should consult my physician or go to the hospital emergency room. I hereby consent to, and assume the risks associated with, the use and consumption of ChiroThin product and agree to follow the recommendations and instructions of my physician. I further agree not to use or consume any ChiroThin product without the advice, counsel, and recommendations of my physician. I hereby release, discharge and agree to indemnify my physician(s), Dr. Daniel O Leary, D.C., ChiroNutraceutical, their agents, servants employees and affiliates from any and all liability, claims, causes of action and demands for personal or bodily injury or death that I or my personal representatives might have or might hereafter acquire through my use or consumption of ChiroThin products. Printed Name: Signature: Date:
3 Patient Name: Date: Patient s Height in Inches: Patient s Current Weight: Patient s Age: Patient s Goal Weight: Calculate Patient s Current BMI: (Weight in Pounds x 703) (height in inches x height in inches) Patient s Current BMI: Patient s Goal BMI: Initial Visit Date: Body Inches Measurement Chart Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Total Lost Neck Shoulder Chest Bicep Waist Hips UpperThigh Calf Start Date: Week 1 Date:
4 Week 2 Date: Week 3 Date: Week 4 Date: Week 5 Date: Week 6 Date:
5 Total Pound Lost: Ending BMI: Total Inches Lost: Ending BP: /
INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM
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Insurance (Let us make a copy of your insurance card and you can skip this section)
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Patient/Guardian Signature Witness Signature
Today s Date Full Name Date of Birth Gender M F Social Security # Email * Home Address City State Zip Home Phone Work Phone Cell Phone Patient Employer Job Title Insurance Subscriber Subscriber Birthdate
MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
Guardian/Patient Name. Family Dental Care NC. 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 SIGNATURE ON FILE
Guardian/Patient Name Family Dental Care NC 1701 Country Club Rd---Jacksonville, NC 28546 Telephone: (910) 346-2345 Date/Initial SIGNATURE ON FILE I authorize use of this form on all my insurance submissions.