2505 W Belt Line Rd
Mon – Fri: 8:00 am – 5:00 pm, Sat – 9:00 am – 5:00 pm, – Sun: Closed
972-230-8290
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Dr. Chiedu Austin Ogwu
JoniRai Schmidt, PA-C
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Primary Care Services
Annual Physicals & Wellness Exams
Weight Loss Program
Urgent Care
School, Sports & College Physicals
Immigration Medical Exams
DOT Physical Exams
MAT for Opioid Addiction
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Weight Loss Form
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ALPHA MEDICAL CENTER
WEIGHT LOSS CLINIC FORM
Patient Name
*
DOB
*
Age
*
Phone # Home
*
Work
*
Cell
*
Email Address
*
Mailing Address
*
What is your current weight?
How many pounds do you want to lose?
Why do you want to lose weight?
Have you tried to lose weight in the past?
Yes
No
If you answered "yes" on #4, were you successful?
Yes
No
If not what made you unsuccessful?
Do you exercise?
Yes
No
If "yes"; How often? times per week
What other medical problems do you have?
Diabetes Mellitus
Hypertension
High Cholesterol
Heart Burn
Shortness of breath
Heart Problems
Joint Pain
Constipation
Thyroid Problems
Other
Would you agree for your picture to be taken at the start of the program, after 6 months, and one year to measure your progress?
Yes
No
If "YES", do you agree for us to show other people your picture as a way to advertise the weight loss program?
Yes
No
Are you ready to start losing weight today?
Yes
No
How many Months can you commit to?
3 months
6 months
12 months
18 months
over 18 months
Patient Signature
*
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Date
ALPHA MEDICAL CENTER
WEIGHT LOSS CLINIC
AGREEMENT FOR PATIENTS USING WEIGHT LOSS MEDICATIONS.
I AM AWARE THAT:
Eating a moderately restricted diet and exercising are the main treatments for losing and controlling weight.
Eating a very restricted diet (1000 calories or less) can be dangerous and will cause metabolism to decrease making weight loss more difficult.
Research shows that generally patients lose weight while on weight loss medications and gain weight when medications are stopped. ONLY by achieving a balance where energy used (exercised away) is equal or greater than the energy taken in (eaten) can weight be maintained or lost.
Based on current scientific research weight loss medications are used as a short-term strategy commonly not more than 3 months. But I will need to work at maintaining weight lost for the rest of my life.
People who have taken any prescription weight loss medication for three months or more in their life have a 23-46 in one million chance of developing pulmonary hypertension a rare but often fatal side effect.
Because of the risks involved I will need and agree to participate in close supervision from the health care team while on weight loss medications.
Patients Signature
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Date
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