Scale Solutions Medical Weight Loss - Richmond Hill Savannah GA

Scale Solutions medical weight loss center in Savannah and Richmond Hill, Georgia

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*Name:

First:

*Last:

M.I

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*Address:

*City:

*State:

*Zip:

*Home Phone:

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*Email address:

*Date of birth:

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*Gender:

Marital Status:

Employment Information

Employer:

Occupation:

Employer Address:

City:

State:

Zip:

Work Phone:

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Social Security #:

Driver's License #:

In Case of Emergency

Name:

Phone: Relationship:

Spouse:

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Family Physician:

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*How did you hear about us?

Medical History

Are you in good health at present?

Yes

Are you currently under a doctor's care?

Yes

If yes, what for?

*List any medications you are taking:
(if none, enter n/a)

Name of Medication:	Dosage:

*List any medications you are allergic to:

(if none, enter n/a)

Check any that you have a history of:

	High blood pressure		Glaucoma
	Diabetes		Heart attack
	Headache		Swelling feet
	Serious injuries

Describe improvements you would like to see in health:

Past medical history:
(Check all that apply)

polio	lung disease	kidney problems
arthritis	drug abuse	cancer
scarlet fever	liver disease	osteoperosis
ulcers	gout	rheumatic fever
thyroid disease	eating disorder	anemia
heart valve disorder	heart disease	psychiatric illness
alcohol abuse	blood transfusion	Other (specify below)

Family history:

	Age	Health	Disease	Cause of Death (if any)	Overweight?
Father
Mother
Brothers
Sisters

Has any blood relative had any of the following:

Glaucoma		Who?
Asthma		Who?
Epilepsy		Who?
High Blood Pressure		Who?
Kidney Disease		Who?
Diabetes		Who?
Psychiatric Disorder		Who?
Heart Disease/Stroke		Who?

Lifestyle Evaluation

*Present weight:

Height: feet inches

When would you like to reach your target weight?
Weight at 20 yrs old:		Weight 1 yr ago:
When did you begin to gain weight?
How long have you been overweight?
What do you feel is the reason for your weight problem?

How many meals do you eat per day?

How many serious attempts have you made at dieting?

How long have you been able to stick to a diet?

What other weight reduction methods have you tried?

Why did you drop out of diets before?

What is the nature of your difficulties while dieting?

Have you been advised by your physician to lose weight?

Yes

List any physical problems that you know are associated with your weight:

Why do you want to lose weight?

Has your spouse/partner encouraged you to lose weight?

Yes

Explain:

How important is it to you to lose weight?

Is your spouse/partner overweight?

Yes

Employment status:

How many children do you have?

List their ages:

Are any of your children overweight?

Yes

Food allergies:

Your highest weight in the last 5 years:

Lowest:

How many times do you eat out per week?

Frequent restaurants:

How many times do you eat fast food per week?

Who plans & prepares meals:

Who does the grocery shopping?

Do you use a list?

Yes

What day/time do you grocery shop?

Food dislikes:

Any specific time you crave food?

Foods you crave:

Do you drink coffee or tea?

Yes

How much daily?

If you drink sodas, what kind?

How much daily?

If you drink alcohol, what kind?

How much daily?

Do you use sugar substitues?

Yes

Do you use butter substitutes?

Yes

Do you awaken hungry at night?

Yes

Do you tend to eat more under stress?

Yes

Are you currently under stress?

Yes

Do you smoke?

Yes

Your worst food habits:

Your snack habits:

Your typical breakfast:

Your typical lunch:

Your typical dinner:

Your typical energy level:

Activity level:

Inactive - no regular activity, sit-down job

Light - no organized physical activity during leisure time

Moderate - occasional activities such as weekend golf, tennis, walking

Heavy - consistent exercise at least 3 times a week

Financial Policy

Thank you for selecting Scale Solutions for your health care needs. We are honored to be of service to you. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services and products will be due at the time services are rendered, unless prior arrangements have been made. For your convenience, we accept Visa, MasterCard, and cash.

* I Agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees and court costs.

* I have read and understand the Patient Informed Consent for Appetite Supressants & Supplements and have agreed to the terms.

*Enter full name (e-signature):

Hours:

Savannah Office
Monday 9-5
Tuesday 9-5
Wednesday 9-6
Thursday 9-5
Friday 7-3

Phone:
912.352.SLIM (7546)
Toll-free:
866.749.SLIM (7546)

Richmond Hill Office Tuesday 8-4
Wednesday 10-6

Phone:
912.756.7597

Pooler Office
Monday 9-5
Wednesday 10-6
Friday 8-4

Phone: 912.748.7547

Bluffton Office
Monday 9-5
Thursday 9-5

Phone: 843.757.4771

Hinesville Office
Tuesday 9-5
Thursday 9-5

Phone: 912.877.7546

Scale Solutions, LLC. Phone: 912-352-SLIM
Enterprise Building 6605 Abercorn Street Suite 107 Savannah, GA 31405 ~ Skin Essentials 10634 Ford Avenue Richmond Hill, GA 31324