SLIM TLC New Patient Form

Name *

First Name Last Name

Date of Birth *

Date

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Cell Phone Number *

Please enter a valid phone number.

Email *

example@example.com

Gender *

Male Female

Weight *

Height *

Ultimate Goal Weight *

To calculate your BMI, visit https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Short-Term Goal Weight *

To Do List (check each one) *

I will set up a 40-minute (“moderate”) appointment with Dr. Cluff (click on the link below) for at least three days from now. I understand that, for three days prior to my visit, I will keep careful track of my eating and exercise habits, and record my weight daily, on the SLIM TLC Food & Exercise Log (click on the link below, and print a copy for each day). I have or will purchase a blood pressure cuff to be able to check my blood pressure and heart rate during each one-on-one visit. I will weigh myself prior to (the day of) each one-on-one visit. I will begin to think of two people (to round out your "TLC Trio") to invite to join me on this journey (you will be able to share your password to SLIM TLC Online with them, and have them join you for the SLIM TLC Virtual/Zoom Group Visits) I will fill in and follow the "SLIM TLC Map" (the goal-setting system found in Lesson #2 of TLC University - part of SLIM TLC Online) to help guide me towards long-term success.

Book an appointment with Dr. Cluff

SLIM TLC Food & Exercise Log

Once you have completed the SLIM TLC Food & Exercise Log for three days, please upload here.

Please indicate: *

I would like to consider a phentermine prescription (prescribed the SLIM TLC way - if you choose this option, review and sign the SLIM TLC Contract below). I do not have a specific dietary preference and am open to what you think is best. I have the following dietary preference (e.g., vegetarian, South Beach, Paleo):*

*Dietary Preference:

How would you describe your eating habits? *

How often do you eat out? *

0-1 time per week 2-3 times per week 4-5 times per week 6 or more times per week

What kinds of fruits, vegetables, grains, nuts, and/or seeds do you like? *

How many sodas do you drink on average per day? *

How much alcohol do you usually drink (include how often)? *

About what percent of your diet consists of "whole" plants?* *

*Whole means eaten whole or prepared without any sugar, oil, white flour, or animal products.

Describe your level of physical activity and exercise type/frequency? *

What are your hobbies and interests? *

What is the most you have ever weighed? *

Describe any weight loss efforts you have made, or programs you have tried, in the past:

Is there anything else you would like us to know about you, or any concerns that you have?

If you desire a prescription of phentermine (prescribed the SLIM TLC way - see below), please carefully review and sign the following:

SLIM TLC Contract

The goal of SLIM TLC is to provide you with long-term health and weight loss. This goal cannot be accomplished unless you become completely self-sufficient by making long-term lifestyle changes. We will help you learn how to do so, but the changes must be made in a framework that is both livable and acceptable to you, to the point that you develop new habits and a new way of life. Phentermine is only a temporary means to that end, and must be seen as such – otherwise, like other efforts you may have made in the past, your success will only be temporary.

"SLIM TLC" has two meanings. Most importantly, it represents becoming SLIM and healthy through “TLC” (Therapeutic Lifestyle Changes). SLIM is also an acronym for the optional use of a Short-term (

Before taking phentermine, it is important that you become fully aware of the potential harms associated with its use. It is a stimulant medicine, and although it is FDA-approved as an appetite suppressant, it is only approved for short-term use – not only because it is potentially addicting, but it also has the potential for several different side effects, e.g., dry mouth, high blood pressure, insomnia, rapid heart rate, tremor, dizziness, irritability, headache, and stomach upset. It is contraindicated in agitated states, high blood pressure, hyperthyroidism, glaucoma, significant heart disease, and a history of drug abuse. The SLIM (Short-term, Low-dose, Intermittent, Mid-day) method of prescribing phentermine significantly reduces these potential dangers, but you must still be vigilant.

Prescriptions for phentermine are written for twenty 18.75 mg doses per month, in the form of ten 37.5 mg scored tablets. You should only take a maximum of a ½ tablet each day. Phentermine should be taken on an empty stomach, either 15-30 minutes prior to lunch or 1-2 hours afterwards. The later you take it in the day, the greater chance for insomnia; however, if it causes insomnia, that is usually a temporary side effect. Do not share this medicine with anyone else, nor seek prescriptions from other providers. Many a patient has “lost” a prescription for a controlled substance or had it “stolen.” Due to the controlled nature and other potential problems associated with the use of this medicine, lost or stolen prescriptions will not be refilled. Please care for your prescription accordingly.

Mark one of the following:

By signing below, I attest that I understand and agree to the above principles and guidelines. I would like to hold off on taking phentermine. I would like to discuss this further with you before deciding.

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See you thin!