Total Wellness & Bariatrics (formerly McCarty Weight Loss)

New Patient Forms

Thank you so much for your interest in Total Wellness & Bariatrics (formerly McCarty Weight Loss)

HEALTH AND MEDICAL HISTORY (Please, fill out as completely as possible.)
Name:*
HEIGHT: *
CURRENT WEIGHT:*
BMI: *

PAST SUGERIES (Please check each that apply) *

	Select	Year	Type
GALLBLADDER SURGERY
SPLEEN SURGERY
ESOPHAGUS SURGERY
STOMACH SURGERY
HERNIA REPAIR SURGERY
CESAREAN SURGERY
ABDOMINAL SURGERY
OTHER SURGERY

Please Explain other surgeries

PREVIOUS WEIGHT LOSS SURGERY: *

	Select	Year
Vertical Banding Gastroplasty
Lap-Band
Roux-en-Y Gastric Bypass
SLEEVE Gastrectomy
Revision Surgery
Stapling (Other restrictive procedure

Other (Please List):
Weight prior to previous weight loss surgery (REVISION PATIENTS ONLY):
Complications due from previous weight loss surgery: (REVISION PATIENTS ONLY)
PLEASE SELECT THE PROCEDURE YOU ARE INTERESTED IN:

Mini SleeveRoux-en-Y Gastric BypassRevisionLap BandBand Fill

MEDICALLY SUPERVISED TREATMENT REGIMENS: (Please list all diets and medications for weight loss that you have used and the treating physician(s): )*

	SELECT	YEAR	PHYSICIAN:
FEN-PHEN
REDUX
ADIPEX
OTHER

OTHER WEIGHT LOSS METHODS ATTEMPTED:*

	SELECT	YEAR
WEIGHT WATCHERS
SLIM FAST
MEDIFAST
NUTRISYSTEMS
SUGAR BUSTERS
HERBALIFE
ADVOCARE
JENNY CRAIG
METABOLIFE
OPTIFAST
LARRY NORTH
XENICAL
SOUTH BEACH
GRAPEFRUIT DIET
ATKINS DIET
DEXATRIM
CAMBRIDGE
MERIDIA
OVEREATERS AN
TOPS
PRITIKIN DIET

MAXIMUM WEIGHT LOST ON ANY PROGRAM YEAR
YEAR
Have any positive and/or negative responses from prior obesity treatments? Explain:
Have you ever been treated for an eating disorder?*

YesNo
(Describe treatment, duration and year)

HEALTH AND WELLNESS INFORMATION("YES" answer list a treating physician)*

	SELECT	YEAR	DIAGNOSING PHYSICIAN:
Shortness of Breath
Snoring
Sleep Apnea Syndrome
CPAP
Shortness of Breath
Asthma
Indigestion/Heartburn
Gastroesophageal Reflux
Degenerative Joint
High Cholesterol
Hyperlipidemia
Hernia Repair History
Irregular Menstruation
Infertility
Fibrocystic Breast

Disease Pain*

	SELECT	YEAR	DIAGNOSING PHYSICIAN:
Lower Back
Hips
Knees
Ankles
Edema/Swelling Legs
Ankles
Congestive Heart Failure
Stroke
Chest Pain

Disease*

	SELECT	YEAR	DIAGNOSING PHYSICIAN:
Depression
Chronic Fatigue
Urinary Incontinence

(Leaking when you cough or sneeze)*

YESNO
Hypertension (High Blood Pressure) SELF*

YESNO
Hypertension Family History*

MotherFatherSibling
Year
DIAGNOSING PHYSICIAN
Diabetes (SELF)*

YESNO
Diabetes (Family History)*

MotherFatherSibling
Year
DIAGNOSING PHYSICIAN
Do you have any underlying medical conditions?*

YesNo
Please Describe
Do you have a Heart Condition?*

YesNo
Please Describe
Is your mother living?*

YesNo
CAUSE OF DEATH
Is your father living?*

YesNo
CAUSE OF DEATH
OTHER FAMILY MEMBERS WHO ARE OBESE?

RECENT TESTING:*

	SELECT	DATE
PHYSICAL
CHEST X-RAY COUYES
UPPER G.I.
ECHOCARDIOGRAM
EKG

INDICATE ANY NEGATIVE RESULTS:

LIST ALL CURRENT MEDICATIONS:*

	Name/Strength	Route	Dose	Purpose	Date Started
1
2
3
4
5
6
7
8
9
10

OTHER COUNTER MEDICATIONS:*

	Name/Strength	Route	Dose	Purpose	Date Started
1
2
3
4
5

DO YOU HAVE ANY MEDICATION ALLERGYS?*

YESNO
LATEX ALLERGYS:*

YESNO
NAME OF MEDICATIONS:

Hiatal Hernia Questionnaire
Have you noticed any acid reflux symptoms?*

YesNo
How long have you had these symptoms?
Please list all the symptoms you've experienced.
Have you used OTC medication to treat your acid reflux?

YesNo
Please indicate
Do you take @ny prescription medication for your acid reflux? (Prilosec, Aciphex, etc.)

YesNo
Please list:
Have you changed your diet due to your acid reflux?

YesNo
How have you changed it?
Does anything you ingest worsen your symptoms? (spicy food, caffeine, alcohol, etc.)

YesNo
Comments:
Does Italian {tomato-based foods} or Mexican food aggravate your symptoms?

YesNo
Comments:
What other methods have you tried to reduce your acid reflux? (changing bed positions, bought newbed, etc. )
Do you experience night-time acid reflux?

YesNo
Comments:
Does lying down or bending over worsen your symptoms?

YesNo
Comments:
Do you ever experience any pain/tenderness in the upper central abdominal area?

YesNo
Comments:
Have you had an EGD (Esophagogastroduodenoscopy) or Colonoscopy in the past 6 months?*

YesNo
Please explain why.
Instructions: please check the box to the right of each question using the scale below.

Scale

0- No Symptoms
1- Symptoms noticeable but not brothersome
2 Symptoms noticeable and bothersome
3- Symptoms bothersome everyday
4- Symptoms affect daily activity
5- Symptoms interfere with daily activities

Question

	1	2	3	4	5
How bad is your heartburn?
Heartburn when lying down?
Heartburn when standing up?
Heartburn after meals?
Does heartburn change your diet?
Does heartburn wake you from sleep?
Do you have difficulty swallowing?
Do you have pain when swallowing?
If you take medication, does this affect your daily life?
How bad is regurgitation?
Regurgitation when lying down?
Regurgitation when standing up?
Regurgitation after meals?
Does regurgitation change your diet?
Does regurgitation wake you from sleep?

Instructions: please indicate which medications you have attempted in the past by
checking the duration of therapy.

Medication

	5 yrs	10 yrs	15+ yrs	Other
Pepcid
Famotidine
Prilosec
Omeprazole
Dexilant
Dexlansoprazole
Protonix
Pantoprazole
Zantac
Ranitidine
Aciphex
Rabeprazole
Prevacid
Lansoprazole
Zegerid
Sodium Bicarb
Tums
Rolaids
Pepto Bismol
Other Medication

Patient Signature:*

Clear
Date:*

MonthDay Year

Weight Loss Consent Form
This very low calorie and/or low carbohydrate plan will be medically supervised. Some of our plans are designed to promote rapid weight loss. Therefore the benefits. adverse effects. and risks are explained below.

Health Benefits:
- Weight loss improves obesity-related conditions such as diabetes. high blood pressure, high cholesterol, sleep apnea, arthritis, depression, etc.
Potential Adverse Effects and Risks:
- Fatigue/Weakness
- Constipation
- Nausea
- Diarrhea
- Lightheadedness/Dizziness
- Headache
- Increased risk of pregnancy: Your current form of birth control:
- Menstual Irregularities
- Acne
- Muscle Cramps
- Arrhythmias
- Electrolyte imbalances (potassium, sodium, magnesium. etc.)
- Gout
- Pancreatitis
- Gallstones
- Hair Loss
- Brittle nails
- Dry skin
- Halitosis (bad breath)
By signing below. you understand. agree. and desire to proceed with one of our four prescribed diet plans.
Print Name*
Signature*

Clear
Date*

MonthDay Year

Authorization to Release Healthcare Information
Patient’s Name:*
Date of Birth*

MonthDay Year
Maiden/Alias Name:*
Social Security #:*
I request and authorize __________________________________________to release healthcare information of the patient named above to:*
Dr. Leah Dill
12222 N. Central Expressway #300,
Dallas, TX 75243
The request and authorization applies to:*

Healthcare information relating to the following treatment, condition, or dates:All healthcare information
Explain
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes Herpes, HPV, Genital Wart, Chlamydia, Condyloma, Syphilis, VDRL, HIV, AIDS and Gonorrhea.
I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.*

YesNo
I authorize the release of any records regarding drug, alcohol or mental health treatment to the person(s) listed above*

YesNo
Patient Signature*

**The Authorization Expires 90 days after date of signature. ** Clear
Date*

MonthDay Year

Authorization to Receive Healthcare Information
**McCarty Weight Loss Center will not disclose any information in regards to appointments, records, or any other information pertaining to your treatment unless listed below. Please include any emergency contacts that you wish to receive information on your behalf.
Patient Name:*
Date of Birth:*

MonthDay Year
Name
Relationship:
Name
Relationship:
Name
Relationship:
Disclosure of Information*

Treatments and/or other information pertinent to my healthcare including payment information.I DO NOT authorize any information to be disclosed to any other parties except to me as the patient.
You may revoke or terminate this authorization by submitting a written revocation to our office to the attention of the Privacy Official or other Authorized Representatives. However, your decision to revoke the authorization will not affect or undo any use of disclosure information that occurred before you notified us of your decision.*

I have received the infonnation Entitled- Notice of Privacy and Practices
Patient Signature*

Clear
Date*

MonthDay Year

BOLD™ Study Patient Information Sheet
Surgical Review Corporation (SRC), a nonprofit healthcare organization, is conducting a study about bariatric/weight-loss surgery. SRC developed the BOLD™ database to support surgeons’ decisions regarding patient care and to track outcomes of bariatric surgeries. BOLD is now the world’s largest database for bariatric surgery, containing information on hundreds of thousands of patients.

WHY IS THIS STUDY BEING DONE?
The purpose of this study is to record and investigate the short-term and long-term results of different types of bariatric surgery. SRC will compare the surgical procedure performed with the health of patients for at least five years after surgery. This information will enable us to learn about the types of surgery that are most effective for weight loss and managing conditions related to obesity.

WHAT ARE THE BENEFITS OF THE STUDY?
The information and knowledge gained from the BOLD study will help surgeons improve the way bariatric surgical care is delivered and better understand the risks and benefits of each type of bariatric surgery.

WHO IS TAKING PART IN THE STUDY?
All patients who have bariatric surgery performed by a surgeon who utilizes the BOLD database are included in the BOLD study.

HOW IS THE STUDY CONDUCTED?
As part of your surgeon’s involvement in the BOLD study, he/she collects the following information for every bariatric surgery patient and enters it into the BOLD database:

Personal information: gender, race, employment status, insurance status, medical record number, year of birth, height, weight and prior surgeries. Your surgeon has the option of entering your name for internal tracking purposes. Information about your surgery: date of admission, date of surgery and date of discharge.

Information about your medical condition before, during and after your surgery.

Data that is used for research does not include your name or medical record number. Information about your surgery will be combined with data from ali other study participants in a separate research database, and SRC research staff will analyze this combined information. The results of the study will be reported or published for the total population no individual patient information will be published.

WHAT ABOUT MY CONFIDENTIALITY?
Your information is entered into BOLD through a secure website and permanently stored in a database that is managed by SRC. This database is secure and meets the requirements for the protection of patient confidentiality as required by the Health Insurance Portability and Accountability Act (HIPAA).

Your privacy is further protected by a Certificate of Confidentiality from the National Institutes of Health. This certificate means that SRC and surgeons submitting data to BOLD cannot be forced to disclose information that may identify you, even by a court subpoena, in any federal, state or local legal proceeding. However, the certificate does not restrict you from voluntarily disclosing your information.

WHAT ARE THE RISKS OF THE STUDY?
There are no physical risks associated with this study. However, there is a slight risk of loss of confidentiality. Every effort is made to keep your information confidential, but this cannot be guaranteed.

WHAT ARE THE COSTS?
There are no costs to you or your insurance provider for participating in the BOLD study, and no additional medical or surgical procedures or tests are performed as part of the study. You will not be paid for participating in the study, and SRC assumes no responsibility for paying, discounting or providing free medical care before, during or after your surgery.

WHAT ARE MY RIGHTS?
Your participation in the BOLD study is voluntary. You do not have to take part in this study in order to have bariatric surgery. You may withdraw from the study at any time. If you withdraw from the study, your data will not be used for research purposes. Your decision to not participate in or to withdraw from the study will not affect your medical care in any way. If you decide to withdraw from the study, you will need to let your surgeon know in writing. You are not required to sign a consent form to participate in this study. However, you must let your bariatric surgeon or his/her staff know if you do not wish to participate either before you leave the office today or prior to your surgery.

You will receive a copy of this information to take home with you. If you are a minor, this information is being provided to you and your parent or legal guardian.

If you have any questions about the BOLD study, please visit www.surgicalreview.org/bold/bariatric or call SRC Support at 1-866-790-4772.
Signature*

Clear

MEDIA RELEASE AND REFERRAL FORM
Media Release
I, _______________________, grant permission to McCarty Weight Loss Center to use my image (photographs and/or video) for use in Media publications including:
(Check All That Apply)

VideosMarketing MaterialsGeneral PublicationsWebsite and/or Affiliates (i.e. Private Facebook Group)
I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.
Signature*

Clear
Date*

MonthDay Year
Name (please print):*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Referral
When researching and finding a Bariatric Surgeon that fits your needs, sometimes speaking with past patients can help with making a decision. McCarty Weight Loss Center provides a supportive network that helps offer patient experiences and testimonies. If you would be willing to act as a referral to future patients, please provide your information below. Your contact information will not be posted, however will be given to serious inquires upon request only and you will be notified.
Phone Number*
Email Address*
Signature*

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Should you wish to not be a part of any publications, we do understand! Instead, please leave us a review on Google, Yelp, Facebook, or Real Self in order to help others find us at McCarty Weight Loss Center. We appreciate your decision to have Dr. McCarty and his staff help you along this exciting journey!

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New Patient Forms

INSURANCE INFORMATON