SLIM TLC® New Patient Form

Name*

First NameLast Name

Date of Birth*

Date

How did you hear about SLIM TLC® (if word of mouth, please include name)?*

Medical conditions (please include all)*

Type "None" if applicable.

Medications (please include all prescription and over-the-counter meds) *

Type "None" if applicable.

Current 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*

Please indicate:*

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 week2-3 times per week4-5 times per week6 or more times per week

How many sugared beverages do you drink on average per day (including juice)?*

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 healthily, i.e., 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?*

What were the circumstances surrounding that weight gain?*

What is currently motivating you to lose weight, i.e., why is it important to you?*

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

My medicine preference*

PhentermineWegovy (semaglutide) or Zepbound (tirzepatide)Both phentermine and one of the above (SLIM TLC® Supercharged!)I have questions and would like to discuss first.

What are your intentions with the medicine and how long you'd like to be on it?*

I'd like to be on it as long as it takes to achieve my goals, and then wean off if at all possible.I would just like a boost to get me going in the right direction, then after I've lost several pounds I'd like wean off the medicine as soon as possible.I haven't thought about it enough to be able to choose one of the above.

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

To Do List (check each one)*

I will set up my initial appointment with Dr. Braswell or (if Dr. Cluff's patient) Becky (PA-C), followed (ASAP) by my appointment with Marie (Nutrition Coach) by clicking on the links below.I will try to attend at least one SLIM TLC® group visit (in-person or virtual) every month.I will try to carefully review at least one TLC University lesson per month and take (and submit) the associated quiz.I will begin to think of two people (to round out my "TLC Trio") to invite to join me on this journey.I will try to learn and implement the SLIM TLC® eating strategy called "Free Food? Whatever!" (see Lesson #2 of TLC University - part of SLIM TLC® Online).I will try to submit one of the SLIM TLC® tools once monthly (SLIM TLC® "Light" Log, SLIM TLC® Map, or SLIM TLC® Whatever! Item and Wcal© Tracker), corresponding with the SLIM TLC® Intensity Level(s) I choose, through the Elation Passport patient portal.I understand that the above components are critical to developing longstanding Therapeutic Lifestyle Changes, which are necessary if I hope to maintain weight loss that is achieved by taking any weight loss medicine or supplement.

Regarding the SLIM TLC® Tools:*

I am comfortable with you using any SLIM TLC® tool I submit (SLIM TLC® "Light" Log, SLIM TLC® Map, or SLIM TLC® Whatever! Item and Wcal© Tracker), minus any visible personally identifiable information, in your educational or promotional materials, and to extract data for the same or for research purposes.I would not be comfortable with you using my SLIM TLC® tools in your educational or promotional materials, but I would be comfortable with you extracting data (minus any personally identifiable information) for educational or promotional materials, or for research purposes.

Next tasks:

1a) If you are starting SLIM TLC® with Phentermine or SLIM TLC® with Injectables and haven't yet met with Dr. Braswell or Becky, book an appointment for 20 minutes to initiate medicine:

With Dr. Braswell
(Only if you are Dr. Cluff's patient) with Becky Maxwell, PA-C

1b) If you are starting SLIM TLC® Supercharged!, book an appointment for 40 minutes to initiate medicine, or if you have questions and would like to discuss first:

With Dr. Braswell
(Only if you are Dr. Cluff's patient) with Becky Maxwell, PA-C

2) Book an appointment with Marie (to help set up your SLIM TLC Map)

For Important Safety and Summary Warnings, see phentermine, Ozempic/Wegovy and/or Mounjaro/Zepbound.

I attest that (check each one):*

I have carefully read and understand the appropriate Important Safety and Summary Warnings referenced above.If desiring phentermine, I do not have a history of glaucoma, an overactive thyroid (hyperthyroidism), a history of cardiovascular disease (e.g., coronary artery disease, stroke, arrhythmias, congestive heart failure, uncontrolled hypertension), agitated states, or a history of drug abuse. I am not taking other stimulants. I have also not taken a monoamine oxidase inhibitor (MAOI) in the last two weeks.If desiring Wegovy or Zepbound, I do not have a family history of medullary thyroid cancer or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), a history of pancreas or kidney disease, I am not pregnant or breastfeeding, or plan to become pregnant or breastfeed, and I am not taking insulin or sulfonylureas (e.g., glipizide or glyburide).If desiring Wegovy or Zepbound, I will contact my doctor immediately if I have pain in the upper abdomen (which may be a sign of pancreatitis) or other untoward side effects, including nausea, gastroparesis (where the stomach stops pushing food into the small intestine), and suicidal thoughts.

Please let us know if you have any questions or concerns:

Signature*

See you thin!