Decalo Medical Group, LLC and entire medical, clinical and administrative staff would like to welcome you to our clinic and look forward to meeting you on your first visit. The weight reduction program here at Decalo is customized for each patient to best meet the individual needs of the patient. The programs take into account habits, lifestyle, medical history, allergies or intolerances, medications taken on a regular basis, special dietary needs, body composition, and the goals of each patient.
To help you prepare for your first visit, please read thoroughly and complete all of the forms in the new patient packet.
If you have any questions, please feel free to contact our office at 301-567-2557
We look forward to partnering with you in your weight loss program!
Thank you for your interest in DECALO Weight Loss Therapy. We work to understand the whole picture of our patients and therefore we ask for a significant history prior to the initial visit. Thank you for taking the time to complete this somewhat long form. We look forward to discussing the information you provide.
CURRENT MEDICATIONS/ SUPPLEMENTS
Please list any prescription, over the counter (OTC) medications, or vitamins/ supplements you are currently taking and dosages:
PAST SURGICAL HISTORY
OB/GYNE HISTORY (Females Only)
(Note: MGM- maternal grandmother; MGF – maternal grandfather; PGM- paternal grandmother; PGF – paternal grandfather; maternal – mother’s side; paternal – father’s side)
PREVIOUS WEIGHT LOSS HISTORY
Your diet history will be discussed during your initial visit. All efforts are relevant, even those with minimal or no weight loss. Please list all significant diet efforts for the past 5 years
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Participation in a Weight Management Program
When you decided to learn more about managing your weight, you took an important step toward improving your health. The health professional who is advising you can help you develop comprehensive weight management skills while you lose a meaningful amount of weight. The calorie deficit and portion-controlled diets are used with patients who are overweight and who may have significant medical problems related to obesity. Such problems may include hypertension, coronary artery disease, diabetes, lung, joint or bone disease, and the need for non-emergency surgery. They have been described and evaluated in many professional medical journals.
Your success will depend upon your commitment to understanding and fulfilling your obligations in a course of treatment. It is important that you be willing to.
- Provide honest and complete answers to questions about your health, weight problem, eating activity and lifestyle patterns so your health care professional can better understand how to help you.
- Devote the time needed to complete and comply with the course of treatment your health professional has outlined for you, including assessment, treatment, and maintenance phases. We will not be able to release any medications, injections, products, supplements without an evaluation by the doctor or medical staff. We at Decalo Medical Group, LLC. will not be able to release your medications, injections, products, or supplements to any other individual. We are responsible for your care and your health is of utmost importance to us.
- Work with your health care professional and others who may participate in helping you manage your weight loss, including keeping a daily food, activity, exercise, fluid and sleep diary, attending your consultations regularly if appropriate, and following your diet and exercise regimen.
- Allow your health care professional to share information with your personal physician.
- Make and keep follow-up appointments with your physician and have any blood tests taken or any other diagnostic measures made which your physician may deem necessary during your course of treatment.
- Follow your exercise program within the guidelines given to you by your health care professional and your physician.
- It is vitally important for you to advise the clinic staff of ANY concerns, problems, complaints, symptoms, or questions even if you may think it is not terribly important, so the physician can determine if you should be seen more often. Keeping the clinic informed of any questions or symptoms you have, affords the best chance of intervening before a problem becomes serious
If you do not have a personal physician, you must agree to find a primary care provider to assist in managing your medical care. Your signature represents your permission, understanding and commitment to the above commitments to the weight reduction program
I. Procedures and Alternatives:
- I authorize Decalo Medical Group, LLC and clinicians/medical staff to assist me in my weight reduction efforts. I understand that my program may consist of a balanced low calorie diet, a regular exercise program and instruction in behavior modification techniques. Other treatment options may include a variety of other diet approaches depending on the needs of the individual.
- I understand it is my responsibility to follow the instructions carefully and to report any significant medical problems that I think may be related to my weight control problem as soon as reasonably possible to the physician or medical staff treating me.
- I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand my continuing to receive treatment will be dependent on my progress in weight reduction and weight maintenance.
- I understand the medical exam by the Physician is not a complete physical exam. I have been advised that I still need to consult with my Primary Care Physician for regular physical exams.
- I understand that Phentermine or any other weight loss medication should not be taken during pregnancy, due to the chance of damage to the fetus. This has been explained to me fully, and I am aware of the risks involved. To the best of my knowledge, I am not pregnant. I am aware of the precautions that should be taken to avoid pregnancy while I am on medication. If I become pregnant, I will advise both the clinic and my OB/GYN immediately.
II. Informed Consent for Appetite Suppressants:
- I understand my treatment may involve, but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling.
- I have read and understand my doctor’s statements that follow:
Medications, including the appetite suppressants, have labeling worked out between the makers of the medication and the Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter term studies (up to 12 weeks) using the dosages indicated in the labeling. As a weight management physician, I have found the appetite suppressants helpful for periods in excess of 12 weeks, and at times in larger doses than those suggested in the labeling. As a physician, I am not required to use the medication as the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and at times, in increased doses. Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there would be serious side effects. I believe that the probability of such side effects is outweighed by the benefit of the appetite suppressant use for longer periods of time and when indicated in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help the appetite suppressants use in this manner may give.”
- I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight and significant medical problems that I think may be related to my weight control program as soon as reasonably possible
- I understand the purpose of this treatment is to assist me in a desire to decrease my body weight and to maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.
- I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced calorie counting program or an exchange-eating program without the use of the appetite suppressant would also prove successful if followed.
III. Risks of Proposed Treatment:
The possibility always exists in medicine that the combination of any significant disease with methods employed for its treatment may lead to previously unobserved or unexpected ill effects, including death. Should one or more of these conditions occur, additional medical or surgical treatments may be necessary. In addition, it is conceivable other side effects could occur which have not been observed to date.
Reduced Weight: When you reduce your caloric intake to a level lower than the number of calories your body uses in a day, you will lose weight. In addition, your body makes other adjustments in physiology. In some participants, there have been rapid improvements in blood pressure and blood sugar levels. Other adjustments may be experienced as temporary side effects or discomforts. These may include an initial loss of body fluid through increased urination, momentary dizziness, a reduced metabolic rate or metabolism, sensitivity to cold, a slower heart rate, dry skin, fatigue, diarrhea or constipation, bad breath, muscle cramps, a change in menstrual pattern, dry and brittle hair or hair loss. These responses are temporary and resolve when calories are increased after the period of weight loss.
Reduced Potassium Levels: The calorie level you will be consuming has been decreased and it is important that you consume the calories which have been prescribed in your diet to minimize side effects. Failure to consume the regimented foo, fluids and nutritional supplements or taking a diuretic medication (water pill) may cause low blood potassium levels or deficiencies in other key nutrients. Low potassium levels can cause serious heart irregularities and more noticeably leg cramps, heartburn, nausea and vomiting. When someone has been on a reduced calorie diet, a rapid increase in calorie intake, especially overeating or bingeeating, can be associated with bloating, fluid retention, disturbances in salt and mineral balance, or gallbladder attacks and abdominal pain. For these reasons, following the diet carefully and following the gradual increase in calories after weight loss is essential.
Gallstones: Overweight people develop gallstones at a rate higher than normal weight individuals. The occurrence of symptomatic gallstones (pain, diagnosed stones and/or surgery) in individuals 30 percent or more over the desirable body weight not undergoing current treatment for obesity is estimated to be 1 in 100 annually, and for individuals who are 20-30 percent overweight, about onehalf that rate, or 1 in 200 annually. It is possible to have gallstones and not be aware of the condition. One study of individuals entering a weight loss program showed that as many as 1 in 10 had "silent" gallstones at the onset. As body weight and age increase, so do the chances of developing gallstones. These chances double for women, women using estrogen, and for smokers. Losing weight, especially rapidly, may increase the chances of developing stones or sludge and/or increasing the size of existing stones within the gallbladder. Should any symptoms develop let your physician and health care professional know immediately. The most common symptoms of symptomatic gallstones are fever, nausea, vomiting and a cramping pain in the right upper abdomen. If you know or suspect that you may already have gallstones, please inform the medical staff during your consultations. Gallbladder problems may require medication or surgery to remove the gallbladder, and, less commonly, may be associated with more serious complications of inflammation of the pancreas or even death. There are medications which are currently available which may help prevent gallstone formation during rapid weight loss. You may wish to discuss these medications or your concerns with your primary care or weight management physician for more information.
Pancreatitis: Pancreatitis, or an infection in the bile ducts, may be associated with the presence of gallstones and the development of sludge or obstruction in the bile ducts. The symptoms of pancreatitis include pain in the left upper abdominal area, nausea, and fever. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Also associated with pancreatitis is long-term abuse of alcohol, the use of certain medications and increased age. Pancreatitis may require surgery and may be associated with more serious complications including death.
Pregnancy: If you become pregnant, report this to your health care professional and physician immediately. Your diet must be changed promptly to avoid further weight loss because a restricted diet could be damaging for a developing fetus. You must take precautions to avoid becoming pregnant during the course of weight loss. Your medications and injections must also be adjusted to prevent damage to the developing fetus.
Binge Eating Disorders: Binge eating disorder is defined as the habitual, uncontrolled consumption of a large amount of food in a short period of time. Participation in a calorically restricted diet has been shown in one study to increase binge eating episodes temporarily. Several other studies demonstrated reduced episodes of binge eating following a calorie deficit and portion-controlled diet. Extended binge eating episodes are associated with weight gain.
Vitamins and minerals: Vitamins and minerals have been shown to cause side effects such as nausea, rash, constipation, and diarrhea. Advise your health care professional and/or physician if you are experiencing these side effects.
Thyroid Conditions: With weigh reduction programs and medications, side effects of vomiting, increased heart rate, chest pain, nervousness, tremors, menstrual irregularity, and/or nausea have also been associated with intake of medications and changes in the body weight.
- I understand that if I develop side effects from the weight reduction program, diet, medications, supplements, vitamins, injections, therapies or alternatives, I will discontinue the weight reduction program, diet, vitamins, supplements, injections, therapies, alternatives and/or the medication(s) and notify the medical staff as soon as possible. I also understand that if the problem is worrisome or severe, I will go to the nearest Emergency Room or see my primary medical doctor as soon as possible. (Please take your medications with you.)
IV. Risks associated with Being Overweight or Obese:
Obesity is a chronic condition, and the majority of overweight individuals who lose weight have a tendency to regain all or s ome of it over time. Factors which favor maintaining a reduced body weight include regular physical activity, adherence to a restricted calorie, low fat diet, and planning a strategy for coping with weight regain before it occurs. Successful treatment may take months or even years. Medical studies of calorie deficit/portioned-controlled diets have shown varying results for percentage of patients who maintain weight loss. In some studies, the percentage has been fewer than 5% of the patients after five years. A group of patients who have been followed for 3 years show that patients have maintained about one half of initial weight loss. Additionally, if you have had fluctuations in your weight in the past, it may be more difficult to maintain the weight you lose during and after this program. Recently published medical studies indicated people whose body weight fluctuates greatly or often have a higher risk of heart disease and death compared with persons of relatively stable body weight, and such weight fluctuations may play a role in the development of other chronic diseases.
Patients with morbid obesity, particularly those with serious hypertension, coronary artery disease, or diabetes mellitus, have a statistically higher chance of suffering sudden death when compared to normal weight people without such medical problems. Rare instances of sudden death have occurred while obese patients were undergoing medically supervised weight reduction, though no cause and effect relationship with the diet has been established. The possibility cannot be excluded that some undefined or unknown factor in the treatment program could increase this risk in an already medically vulnerable patient.
You have a right to leave treatment at any time although you do have a responsibility to make sure the physician knows you ar e discontinuing treatment and to verify your physician is able to assume medical care for you after you leave treatment.
- I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies for high blood pressure, diabetes, heart attack, heart disease and arthritis of the hips, joints, knees, back and feet. I understand that these risks may be modest if I am not significantly overweight but the risks increases significantly with increased weight.
- I understand that thirty (30) to forty (40) percent of overweight or obese patients may have or develop gallstones. A large percentage of this group will develop symptomatic gallbladder disease during their lifetime. I understand that certain types of weight reduction programs may increase the chance of developing symptomatic gallbladder disease.
V. Potential benefits:
Medically-significant weight loss (usually about 10 percent of initial weight, or as an example, losing 20 pounds from 200 pounds starting weight) can:
- Lower blood pressure and/or reducing the risks of hypertension
- Lower cholesterol and/or reducing the risks of heart and vascular disease
- Lower blood sugar and/or reducing the risks of diabetes
If you are taking medications for one or more of these conditions, dosages may need to be adjusted as your overall health improves. You agree to see your physician as needed to have your need for these medications reassessed accordingly. Your health care professional will share your results with your physician on a regular basis so the physician is informed about your progress with your consent.
Other benefits may also be obtained. Increasing activity level can favorably affect the above conditions and has the additional benefit of helping you sustain weight loss. Weight loss and increased activity provide important psychological and social benefits, as well.
VI. Notice of Personal Health Information Practices (HIPPA Privacy Notice)
This notice describes how information about you may be used and disclosed and how you can get access to this information when necessary. Please review it carefully.
At Decalo Medical Group, LLC we are committed to treating information about you and your health responsibly. This notice of health information practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protective health information. This notice is effective March 1, 2009, and applies to all protected health information as defined by federal regulations.
Understanding Your Health Record and Information: Each time you visit Decalo Medical Group, LLC, a record of your visit is made. Typically, this record may contain your symptoms, examination, test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as:
- A basis for planning your care and treatment
- A means of communication among many health professionals who contribute to your care,
- A legal document describing the care you received,
- A means by which you a third party can verify that services were actually provided,
- A tool in educating health professionals,
- A source of data for our planning and marketing,
- A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who may access your health information, and make more informed decision when authorizing disclosure to others.
Your Health Information Rights: Although your health record is the physical property of Decalo Medical group, LLC, the information belongs to you. You have the right to:
- Inspect and copy your health record
- Obtain an accounting of disclosures of your health information
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Our Responsibilities: Decalo Medical Group is required to:
- Maintain the privacy of your health information
- Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
- Abide by the terms of this notice
- Notify you if we are unable to agree to a requested restriction.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have supplied us, or if you agree, we will e-mail the revised notice to you. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue using or disclosing your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.
For more information or to Report a Problem: If you have questions and would like additional information, you can contact us at (301) 567 2557.
- I understand the HIPPA policy is available in the office and on the clinic web site for all patients to review.
AKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE : By signing this document, you acknowledge that Decalo Medical Group has given you a copy of its Privacy Notice, which explains how your health information will be handled in various situations.
- If there are any individuals with whom we are permitted to share your medical information, please provide their names(s) here:
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VII. No Guarantees
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 I will have to continue watching my weight if I am to be
I understand that I will not receive any refund for any treatment, medications, injections, or consultations if I am not successful.
I understand that there is an initial fee, a fee every visit and a fee for products.
I understand that I will not be able to return or receive funds for any product I purchase. It is my responsibility to inspect
products before I leave the facility.
VIII. Financial responsibility
Thank you for selecting Decalo Medical Group, LLC. for your Medical Weight Loss Management. Please be advised that payment of all services is due at the time services are rendered. We do not bill insurance companies for any medical weight loss services rendered Decalo Medical Group, LLC. For your convenience, we accept major credit cards, cash or flex spending accounts.
I have read and understand all of the above and have agreed to these statements, I understand that I will assume full financial responsibility for all services, medications, injections, products, supplements, vitamins or weight reduction programs rendered.
IX. Weight-Loss Consumer Bill of Rights
WARNING: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1-2 percent of bodyweight per week after the second week of participation in a weight-loss program. Consult your personal physician before starting any weight-loss program. Only permanent lifestyle changes, such as making healthy food choices and increasing physical activity will promote long-term weight loss. You have a right to ask questions about the potential health risks of this program and its nutritional content, psychological support, and educational components, receive an itemized statement of the actual or estimated price of the weight-loss program, including extra products, services, supplements, and examination, and know the actual or estimated duration of the program.
X. Resale of Products:
By signing this informed Consent, you agree that you will not resell any medications, injections, vitamins, supplements, products and/or weight reduction program details purchased through this weight management program.
XI. Childproof Containers
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XII. Pregnancy Waiver
I am reasonably certain that I am not pregnant at this date and time. However, I hereby release Dr. John K. Aziz and the staff of Decalo Medical Group, LLC of any responsibility with regards to the possibility of my pregnancy during my weight reduction program. To my best knowledge, I am not currently pregnant
XIII. Topamax Waiver
I understand that I may be prescribed Topamax or any other craving medications to be taken as directed by the physician or medical staff. I acknowledge that I have been informed by Decalo Medical group, LLC of the possible side effects of taking the Topamax or any other craving or weight reduction medication. I hereby release Dr. John K Aziz and the staff of Decalo Medical Group, LLC of any responsibility should I choose to take the aforementioned medications as prescribed.
XIV. Injection Waiver
I understand that I may be prescribed injections which may include Lipotropic which includes sulfur. I acknowledge that I have been informed by Decalo Medical group, LLC of the possible side effects of the injectable which includes sulfur. If I have already indicated an allergy to sulfur and still request the Lipotropic injection to be given regardless of my allergy, I hereby release Dr. John K. Aziz and the staff of Decalo Medical Group of any responsibility should I elect to take the medication injection.
XV. Pharmacy & Medication Dispensary
I have been made aware that written instructions are available with every prescription and to call 301-567-2557 in the event my prescription(s) have been incorrectly filled or for any questions/concerns.
Your answer to the following questions, will not affect your treatment or pricing.
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PLEASE NOTE: If you've opted to have the medications, prescribed by Decalo Medical Group providers, filled by our onsite dispensary, you can change at any time by notifying the prescribing physician(s). Additionally, if you've opted to have the medications, prescribed by Decalo Medical Group providers, filled at an off-site pharmacy, you can change at any time by notifying the prescribing physiclan(s).
XVI. Referral for Labs:
I understand that if I do not have lab work results with me today, I will still be treated and may be referred for tests to be done at a laboratory of my choice.
XVII. Studies and Research
To advance science, I understand my de-identifying data, with my specimens (blood, tissue and other samples), may be used for research. I understand I can withdraw my consent at any time.
XVIII. Patient's Consent
I have read and fully understand this consent form and I realize I should not sign this form if any items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants or weight loss medications. I acknowledge that I have been provided a copy of Notice of Privacy Practices. I, the undersigned, have reviewed this information with my health care professional or my physician, and have had an opportunity to ask questions and have them answered to my satisfaction.
IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR HAVE ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THIS CONSENT FORM.
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XIX. Physician Declaration:
I have explained the contents of this document to the patient and have answered all their related questions to the best of my knowledge. The patient has been adequately informed concerning the benefits and the risks associated with the use of the appetite suppressants, weight loss medications, injectables, and vitamins or supplements, the benefits and risks associated with allernative therapies and the risks of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving the appetite suppressants in the manner indicated above. I hereby certify that I have explained the nature, purpose, benefits, risks of, and alternatives to, the proposed program and have answered any questions posed by the patient. I fully attest that the patient relative/guardian fully understands what I have explained and answered.
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