Dareld R Morris II D O

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Dareld R Morris II D O,Morris Medical Weight Loss Program. Patient Information Please Print,FIRST NAME LAST NAME. DATE OF BIRTH AGE GENDER SOCIAL SECURITY,Male Female. STREET ADDRESS CITY STATE ZIP,EMPLOYER OCCUPATION,WORK PHONE HOME PHONE. Can we leave a message at this number Yes No Can we leave a message at this number Yes No. CELL PHONE EMAIL ADDRESS,Can we leave a message at this number Yes No.
EMERGENCY CONTACT Last name First name PHONE NUMBER. Supporting you in your journey of weight loss and maintenance is very important to us Therefore from time to time we may wish. to send you information samples or special offers that we may feel may be of interest to regarding Morris Medical Weight Loss. Program and or Zone Wellness We may also contact you in relation to consumer research marketing and customer surveys If. you would rather not receive additional information and or offers please do not check the box below. PRIVACY Your information will be kept strictly confidential and not provided to any third parties. Yes I would like to receive such information offers by postal mail. Yes I would like to receive such information offers by phone. Yes I would like to receive such information offers by email. How did you learn about the program,Patient Referral Newspaper. Magazine Television,Other Please Describe,Dareld R Morris II D O. Morris Medical Weight Loss Program,Weight History,Height Current Weight What is your goal weight. How long have you been trying to lose,What has been your heaviest weight. When were you that weight record your age,When did you first become overweight.
What do you think is the cause of your weight problem. Have you ever stayed the same weight for ten 10 years or more Yes No. Are any members of your household overweight Yes No. If yes please list relation and details, What was your motivation for weight loss before joining our program. Check all that apply, Don t like the way I look Clothes don t fit anymore Feel more confident socially. More energy Improve health Look more attractive for my partner. Better work opportunities Feel better Reduce medications. More mobility Want to wear smaller sizes Want to wear more stylish clothing. Attend a wedding graduation Upcoming vacation Upcoming anniversary birthday. Attend a reunion Look better other please describe. Perform better Live longer,Dareld R Morris II D O,Morris Medical Weight Loss Program. In order to assist you in achieving your weight loss goal please check the programs that you. have previously participated in Please list under comments if you were successful in obtaining. your goal and if not why the program did not meet your expectations. Name of Program Results Why this program fell short of you expectations. Weight Watchers,Jenny Craig,South Beach,L A Weight Loss. Nutri System,Do you exercise If so how often do you exercise.
Never Rarely Daily 4 5 times a week 2 3 times weekly once a week. What is your exercise routine,Check all that apply. Walking Bicycling,Swimming Yoga,Dancing Sports basketball tennis etc. Aerobics Strength training,Pilates Elliptical,Stairmaster Treadmill Jogging. other please describe,Dareld R Morris II D O,Morris Medical Weight Loss Program. Medical History, Family History If blood relative has suffered the following please indicate relationship.
Heart Attack Arthritis,Cancer Diabetes,Hypertension Obesity. Stroke Glaucoma,Epilepsy Other, Have you ever been hospitalized If yes when and why. Year Illness or Operation, Medications Please list the medications you are currently taking and as needed. Medication Dosage How often Reason, Allergies Please list any medications you are allergic to. Medical History,Yes No Yes No Yes No,Loss of hearing Hemorrhoids Anemia.
Ringing in ears Hernia Immune disorders,Ear infections Gall bladder Alcohol abuse. Bad vision Sudden weight loss Drug abuse,Glaucoma Liver disease Hypertension. Nose bleeds Back pain Heart disease,Sinus trouble Joint pain Thyroid disease. Sore throat Broken bones Cancer,Allergies Dizzy spells Diabetes. Hoarseness Fainting spells Stroke,Pneumonia Memory loss Osteoporosis.
Bronchitis Insomnia GERD,Asthma Nervousness Rashes. Short of breath Depression Chicken pox,Tuberculosis Phobias Mumps measles. Heart murmur Manic depressive Polio,Palpitations Anxiety Are you pregnant. Irregular pulse Schizophrenia Could you be Pregnant. Swollen ankles Bulimia Other,Chest pain Anorexia,Loss of appetite Other eating disorders. Indigestion Frequent urination,Stomach ulcers Kidney disease.
Diarrhea Prostate disease,Constipation Headaches,Bloody tarry stools Fatigue. Dareld R Morris II D O,Morris Medical Weight Loss Program. Appetite Suppressant and Weight Loss Consent, I hereby authorize Morris Medical Weight Loss Program and associates to assist me in weight. reduction I understand that my program may consist of a balanced calorie deficient diet regular. exercise program ZONE Wellness and lifestyle changes I also understand that appetite. suppressants other medications and injections may be used in my program for up to and possibly. more than 12 consecutive weeks Appetite suppressants labeling suggestions are based on short. term studies of 12 weeks The experience of Bariatric physicians as well as recent long term. studies of university based investigators has shown that appetite suppressants supplements and. injections are effective for longer than 12 weeks, Morris Medical Weight Loss Program and associates believe in the off label use of medications. proven to be effective in medical studies to promote weight loss and in the use of nutritional. supplements and injections These injections nutritional supplements and medications can help. you lose weight faster and make you feel better while you are losing weight These nutritional. supplements injections and medications can boost your energy burn fat faster and eliminate. cravings There are those practicing Bariatric Medicine that do not hold to these beliefs regarding. the effectiveness of nutritional supplements injections and medications Many of these. physicians believe that in order to lose weight you simply need to exercise or and eat fewer. calories Morris Medical Weight Loss Program and associates disagree with this simplistic. thinking and believes that the nutritional supplements and injections that are prescribed are. effective and therapeutic If you have any problems or questions please inform one of our. medical associates immediately, 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 or an. exchange eating program without the use of the appetite suppressants would likely prove. successful if followed even though I would probably be hungrier without the appetite. suppressants, In order to continue to receive appetite suppressants other medications and injections depends. on continued weight loss The use of appetite suppressants other medications and injections. involves potential risks Reported side effects include nervousness sleeplessness headaches. dry mouth weakness tiredness medication allergy high blood pressure rapid heart beat and. heart irregularities These and other risks could on occasion be serious. I understand that there are risks associated with obesity Among these risks are tendencies to. high blood pressure diabetes heart attack and heart disease arthritis of the joints hips knees. and feet I also understand that thirty to forty percent of overweight or obese patients may have. or develop gallstones A large percent of this group will develop significant gallbladder disease. Dareld R Morris II D O,Morris Medical Weight Loss Program. during their lifetime I also understand that rapid weight loss programs may increase the. incidence of symptomatic gallbladder disease, I understand that if I develop side effects from the diet or the medication I will discontinue the. diet and or the medication and notify a member of your medical staff immediately I also. understand that if the problem is severe I will go to the nearest Emergency room or see my. primary care physician as soon as possible, There is no guarantee that the program will work for me By consenting to treatment I agree to. pay in full for all visits and charges at the time of each visit I understand that your services. are not reimbursed by insurance and that you do not provide or fill out claim forms for. insurance purposes I understand that no refunds are ever given at any time for any reason I. also understand that the medications dispensed to me during my weekly visits are included for. quality assurance and my convenience however I may request that a prescription be written for. the weekly dose of the medication, By signing below I certify that I have read and fully understand this consent form I should not.
sign this form if I have any questions or concerns that have not been answered to my. complete satisfaction My signature further confirms that I do not have a history of alcohol. abuse drug abuse schizophrenia manic depressive illness or history of any eating disorder since. these conditions constitute a contraindication to the use of appetite suppressants I agree not to. take any other appetite suppressants other medications or injections other than those prescribed. by Morris Medical Weight Loss Program or this office s physician or listed on my medical. history form I agree to inform a member of your medical staff of any changes in my medications. If a female my signature confirms that I am not pregnant do not plan to get pregnant and I will. take all necessary precautions to prevent pregnancy during the time I will be taking appetite. suppressants If I become pregnant I will stop the medication immediately and notify your. I further understand that Morris Medical Weight Loss Program and all written materials. describing your program or any of its parts and all applicable trademarks copyrights and other. intellectual property in or to your program and related materials are and remain your absolute. property I acknowledge that I am purchasing a non exclusive non transferable license to use. your program and the related written materials for my own use and that I have no right to. duplicate or to sell lend or otherwise transfer to any other person or to make any commercial use. of our program or related written materials I may not modify publish distribute perform. participate in the transfer or sale create derivative work of or in any way exploit any of the. content in whole or in part, My signature below indicates my consent of treatment. Patient Date,Dareld R Morris II D O,Morris Medical Weight Loss Program. Photographs Consent Form, I hereby authorize Morris Medical Center staff to take my photograph during my initial. consultation during and at the end of my weight loss program I understand that these. pictures are for office purposes only and are kept in my chart at all times. I DO DO NOT Please initial one give permission for my. photographs to be used by Morris Medical Weight Loss Program for marketing or. educational purposes I also understand that if used these photographs will not contain my. name or any other identifying information,Signature Date. Witness Date,For office use only,Dareld R Morris II D O.
Morris Medical Weight Loss Program,Receipt of Notice of Privacy Practices. Written Acknowledgement Form, I have received a copy of Morris Medical Weight Loss Program s. Patient Name, Morris Medical Weight Loss Program s Notice of Privacy Practices. Signature of Patient Date,Dareld R Morris II D O,Morris Medical Weight Loss Program. Patient authorization for disclosure of protected health information. SS authorize Morris Medical Weight Loss Program, and or staff to release information to the following individuals regarding my appointment.
and account history and hereby authorize these individuals to reschedule verify make. cancellation and tender payment on my behalf,Signature Date. Dareld R Morris II D O Morris Medical Weight Loss Program In order to assist you in achieving your weight loss goal please check the programs that you have previously participated in Please list under comments if you were successful in obtaining your goal and if not why the program did not meet your expectations Name of Program Results

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