Spartanburg Location Greenville Location 1463 East Main Street, Suite C, Spartanburg, SC 29307 2082 Woodruff Road, Greenville, SC 29607 Phone (864)585-6400 Phone (864)254-9930

CONFIDENTIAL HEALTH RISK QUESTIONAIRE

NAME: ______________________ ___________________________ ____ DATE OF BIRTH: ___/___/____ LAST FIRST MI

ADDRESS: ______________________________________CITY_________________STATE______ZIP________ CELL PHONE: ________________ CHECK HERE IF YOU DO NOT WANT US TO CONTACT YOU AT THIS NUMBER

EMAIL:___________________________________________________________________________________ MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOW/ER EMPLOYMENT: _________________________________________ ___________________________________

COMPANY JOB TITLE

PRIMARY CARE PHYSICIAN (PCP): ____________________________________ PHONE #: ________________

A. WHAT IS YOUR PERSONAL ASSESSMENT OF YOUR GENERAL HEALTH? GOOD AVERAGE POOR

WHAT CURRENTLY CONCERNS YOU THE MOST ABOUT YOUR HEALTH? ________________________________B. PLEASE LIST ALL THE MEDICATIONS YOU ARE ALLERGIC TO _________________________________________________________________________________________________________________________________C: DO YOU SMOKE? YES NO HOW MUCH? ___________________

YES D: DO YOU DRINK ALCOHOL? NO HOW MANY DAYS PER WEEK? _______ WHEN YOU DRINK HOW

MANY DO YOU HAVE? (5 OZ OF WINE, 12 OZ OF BEER OR 1 OZ OF LIQUOR EQUALS ONE DRINK)______________ E. PLEASE LIST ALL THE NON-PRESCRIPTION MEDICATION YOU ARE CURRENTLY TAKING______________________________________________________________________________________________________________F. DO YOU TAKE ASPIRIN? YES NO HOW MANY DAYS PER WEEK? _______ HOW MANY ASPIRIN? ________ G. PLEASE LIST ALL DIETARY SUPPLEMENTS YOU ARE CURRENTLY TAKING________________________________________________________________________________________________________________________H. PLEASE LIST ALL PRESCRIPTION MEDICATIONS YOU ARE CURRENTLY TAKING____________________________________________________________________________________________________________________I. PLEASE LIST ALL SURGERIES ALONG WITH THE YEAR PERFORMED _____________________________________________________________________________________________________________________________J. PLEASE LIST ANY CHRONIC (MORE THAN A YEAR) ILLNESSES YOU HAVE_________________________________________________________________________________________________________________________K. PLEASE INDICATE WHICH IMMUNIZATIONS YOU HAVE HAD:

DIPTHERIA AND TETANUS WITHIN THE PAST TEN YEARS

MEASLES, MUMPS, RUBELLA IF BORN AFTER 1956 HEPATITIS B PNEUMOCOCCUS

INFLUENZA WITHIN THE PAST 12 MONTHS DATE OF FLU SHOT:_______

L. FAMILY HISTORY. PLEASE INDICATE WHETHER ANY MEMBERS OF YOUR IMMEDIATE FAMILY (PARENTS,GRANDPARENTS AND SIBLINGS) HAVE BEEN DIAGNOSED WITH: DIABETES STROKE CANCER

HIGH CHOLESTEROL HIGH BLOOD PRESSURE HEART DISEASE OBESITY THYROID DISORDER

M. WEIGHT HISTORY: AT WHAT WEIGHT ARE YOU MOST COMFORTABLE? ____________WHEN DID YOUR WEIGHT BECOME A PROBLEM? ___________WHAT WAS YOUR LOWEST WEIGHT AS AN ADULT? ___________ WHEN WAS THAT? __________WHAT IS YOUR HIGHEST NON-PREGNANT WEIGHT AS AN ADULT? _________ WHEN WAS THAT? ________HOW MANY TIMES HAVE YOU TRIED TO LOSE WEIGHT IN THE LAST FIVE YEARS? ______________WHAT WEIGHT LOSS PROGRAMS HAVE YOU TRIED? ______________________________________________LIST ANY PRESCRIPTION OR NON-PRESCRIPTION APPETITE SUPPRESSANTS YOU HAVE TAKEN: ____________________________________________________________________________________________________DID THEY CAUSE YOU ANY DIFFICULTY? YES NO DID THEY HELP YOU LOSE WEIGHT? YES NO

N. PHYSICAL REVIEWCHECK IF YOU CURRENTLY HAVE A LISTED SYMPTOM OR A HISTORY OF THAT SYMPTOM

1. RESPIRATORY:

□ SHORTNESS OF BREATH AT REST

□ SHORTNESS OF BREATH AFTER CLIMBING ONE FLIGHT OF

STAIRS

□ PNEUMONIA

□ ASTHMA

□ PRODUCTIVE COUGH (PURULENT YELLOW OR GREEN

SPUTUM)□ PRODUCTIVE COUGH WITH BLOOD

□ PULMONARY EMBOLI (BLOOD CLOTS IN THE LUNGS)□ EMPHYSEMA BY PHYSICIAN DIAGNOSIS

□ TUBERCULOSIS SKIN TEST IN THE LAST FIVE YEARS

2. CARDIOVASCULAR:

□ CHEST PAIN

□ HEART ATTACK BY PHYSICIAN DIAGNOSIS

□ HEART FAILURE BY PHYSICIAN DIAGNOSIS

□ HIGH BLOOD PRESSURE

□ EDEMA (SWELLING DUE TO FLUID IN THE ANKLES OR LEGS)

□ HEART MURMUR

□ PERIPHERAL VASCULAR DISEASE (POOR CIRCULATION)

3. ENDOCRINE

□ ABNORMAL THYROID FUNCTION

□ DIABETES

□ GOUT

4. GASTROINTESTINAL

□ ABDOMINAL PAIN □ BELCHING

□ HEARTBURN □ ULCER DISEASE

□ HIATAL HERNIA □ ACID REFLUX

□ VOMITING □ EXCESSIVE GAS

□ RECTAL BLEEDING □ NAUSEA

(BLACK STOOLS) □ CONSTIPATION

□ HEMORRHOIDS □ COLITIS

□ GALLSTONES □ SEVERE HEARTBURN

□ DIARRHEA

HAVE YOUR STOOLS BEEN TESTED FOR BLOOD IN THE LAST TWO

YEARS? YES NO

5. PSYCHOLOGICAL

□ DEPRESSION OR BIPOLAR DISORDER

□ SCHIZOPHRENIA

□ CHRONIC ANXIETY

□ PANIC ATTACKS

□ HISTORY OF ANY EATING DISORDERS

6. NEUROLOGICAL

□ HEADACHES

□ FAINTING

□ SEIZURE DISORDER

□ NUMBNESS

□ DIZZINESS

7. MUSCULOSKELETAL

□ ACHING JOINTS

□ LIMITATIONS ON MOBILITY

□ LOW BACK PAIN

□ ARTHRITIS

□ MUSCLE CRAMPS

8. EARS, EYES, NOSE AND THROAT

□ SEASONAL ALLERGIES

□ SIGNIFICANT HEARING LOSS

□ DIFFICULTY SWALLOWING

□ GLAUCOMA

□ GLASSES OR CONTACTS

□ CATARACTS

9. GENITOURINARY

□ FREQUENT NIGHTTIME URINATION (2+ TIMES PER NIGHT)□ RECURRENT URINARY INFECTIONS (1+ PER YEAR)□ BLOODY URINE

□ DIFFICULTY URINATING

□ SUDDEN URGE TO URINATE (8+ TIMES PER DAY)□ BURNING URINATION

MEN ONLY: HAS PSA BEEN DETERMINED IN THE PAST YEAR? YES NO DO YOU ROUTINELY EXAMINE YOUR TESTICLES? YES NO

10. SKIN

DO YOU HAVE YOUR SKIN EXAMINED REGULARLY? YES NO DO YOU PROTECT YOURSELF IN THE SUN:

WITH CLOTHING? YES NO WITH SUNSCREEN? YES NO WITH SUNGLASSES? YES NO

11. DENTAL

DO YOU VISIT THE DENTIST EVERY SIX MONTHS FOR ROUTINE

CHECKS AND CLEANING? YES NO DO YOU FLOSS REGULARLY? YES NO

12. WOMEN ONLY:

ARE YOUR MENSTRUAL PERIODS REGULAR? YES NO ARE YOU POST-MENOPAUSAL? YES NO

DO YOU HAVE HEAVY MENSTRUAL FLOW? YES NO HAVE YOU BEEN DIAGNOSED ANEMIC? YES NO HAVE YOU BEEN PREGNANT? YES NO BIRTH WEIGHT OF YOUR HEAVIEST BABY? ______ HAVE YOU EVER HAD A DIFFICULT PREGNANCY? YES NO

EXCESSIVE EDEMA HYPERTENSION

GESTATIONAL DIABETES DID YOU BREASTFEED? YES NO DO YOU ROUTINELY EXAMINE YOUR BREASTS? YES NO DO YOU HAVE ANNUAL BREAST AND PELVIC EXAMS AND PAP

SMEARS? YES NO DO YOU HAVE ANNUAL MAMMOGRAMS? YES NO DO YOU TAKE HORMONE REPLACEMENT? YES NO

NUTRITION & EXERCISE HISTORY

NO

DO YOU DRINK PLAIN WATER EVERY DAY? YES NO

WHAT OTHER BEVERAGES DO YOU DRINK? ____________________________ DO YOU EAT BREAKFAST REGULARLY? YES NO

DO YOU EAT CEREAL REGULARLY? YES NO DO YOU USE MILK? YES NO WHAT TIME OF DAY DO YOU MOST NOTICE AN APPETITE? ○ MORNING ○ AFTERNOON ○ EVENING

IF YOU SNACK, WHEN DO YOU SNACK? ○ MORNING ○ AFTERNOON ○ EVENING

WHAT IS YOUR TYPICAL SNACK FOOD? _____________________________________________ HOW OFTEN DO YOU EAT FISH? ___________________________________________________

FOR THE NEXT QUESTIONS: ½ CUP OF MOST VEGETABLES AND BEANS AND 1 CUP OF LEAFY GREEN VEGETABLES OR FRUIT = 1 SERVING.

HOW MANY SERVINGS OF VEGETABLES DO YOU EAT PER DAY?__________________________ WHICH VEGETABLES DO YOU PREFER? __________________________________________

HOW MANY SERVINGS OF FRUIT DO YOU EAT PER DAY?________________________________ WHICH FRUITS DO YOU PREFER? _______________________________________________ DO YOU EAT OR DRINK DAIRY PRODUCTS? YES NO

WHICH ONES?______________________________________________________________ DO YOU EAT MARGARINE? YES NO DO YOU EAT PACKAGED BAKERY GOODS? YES NO

WHICH ONES?

DO YOU CLIMB STAIRS ON A REGULAR BASIS? YES HOW MANY FLIGHTS? ________

ARE YOU PHYSICALLY ACTIVE AT YOUR JOB? YES NO

DO YOU DO YOUR OWN HOUSEWORK? YES NO

DO YOU DO YOUR OWN YARDWORK? YES NO

HOW MANY TIMES A WEEK DO YOU EXERCISE? ____________ TYPICAL EXERCISE ACTIVITY:___________________________________FOR________MINUTES DO YOU DO ANY STRENGTH TRAINING? YES NO DO YOU STRETCH REGULARLY? YES NO

HAVE YOU PARTICIPATED IN ORGANIZED SPORTS? YES NO WHAT SPORTS?____________________________________________________________ _________________________________________________________________________ WHEN AND FOR HOW LONG?__________________________________________________ _________________________________________________________________________

The following pages will be signed when you come into the office.

They are included here for review purposes only.

2082 Woodruff Road 1463 East Main Street, Suite C Greenville, SC 29607 Spartanburg, SC 29307 (864) 254-9930 Patient Informed Consent (864) 585-6400

I. AUTHORIZATION TO PRESCRIBE MEDICATIONS AND/OR ADMINISTER B12 INJECTIONS.

I am requesting the physicians and staff of Nutritional Health Center to assist me in my health improvement and weight management efforts. I hereby authorize them, at my request, to administer vitamin B12 injections and/or to prescribe and dispense one or more of the following prescription medications: phentermine, phendimetrazine, diethylpropion and furosemide.

II. ACCEPTANCE OF RISKS OF PROPOSED TREATMENT.

I understand that there is a potentially deadly overdose risk with all medications and that I will take any medications I receive from Nutritional Health Center only as directed. I understand that even if I take these medications as prescribed there is still a risk of negative side effects, which are usually minor but may become more serious, including: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, allergic reactions, high blood pressure, rapid heartbeat and other heart irregularities. I am accepting these and all other risks associated with these medications. I understand that there are potential risks associated with vitamin B12 injections, most seriously allergic reaction and infection. I am accepting these and all other risks associated with these injections.

III. RISKS ASSOCIATED WITH BEING OVERWEIGHT OR OBESE.

I am aware that there are risks associated with remaining overweight or obese including high blood pressure, diabetes, heart attack, heart disease, sleep apnea, arthritis and other joint problems. I understand that these risks may be modest if I am not very overweight but increase the more overweight I am. I understand that it is my responsibility to weigh these risks against the risks associated with treatment.

IV. NO GUARANTEE.

I understand that my success depends on my own efforts and therefore there can be no guarantee that the program will be successful for me. I also understand that I will have to continue watching my weight and maintaining a healthy lifestyle for the rest of my life to be successful.

V. SPECIAL PROCEDURES.

I understand that Nutritional Health Center may implement special procedures for events such as the COVID-19 pandemic by allowing curbside pickup of prescriptions and B12 shots (to be self-administered). These procedures may reduce my health risk in one way but increase my risk in other ways. By choosing to take advantage of these procedures I am assuming all the risks involved.

VI. ASSUMPTION OF RISK.

By signing this form I am acknowledging that I have read it in its entirety and understand the potential risks of being treated at Nutritional Health Center. I am assuming all the risks associated with the treatment I am seeking and will not hold Nutritional Health Center, LLC, its physicians or its staff responsible for any harm that may come to me as a result of the treatment I receive.

___________________________________________ __________________________________________ Signature Date

FINANCIAL POLICY AND PAYMENT RESPONSIBILITY

Payment is required at the time of service and is the responsibility of the patient or, in the case of a minor, the signed responsible party. OUR OFFICES DO NOT FILE FOR ANY INSURANCE BENEFITS. It is the patient’s responsibility to file all claims with his or her insurance company. This office will, upon request, provide an itemized bill at the time of the visit which indicates a diagnosis code and, where applicable, CPT codes to aid the patient in seeking reimbursement. Other than this itemized bill, WE ARE UNABLE TO PROVIDE ANY FURTHER ASSISTANCE IN SEEKING REIMBURSEMENT. In our experience, we have found that MOST INSURANCE WILL NOT COVER ANY EXPENSES FOR MEDICAL WEIGHT LOSS PROGRAMS.

Acceptable methods of payment are: CASH, CHECK, VISA, MASTERCARD and DISCOVER. We charge $25 for dishonored checks to cover our bank fees. By signing below you are agreeing to our payment policies.

We are not a participating Medicare provider. If you are covered by Medicare you may be able to find a participating provider to provide you with weight loss and nutritional services without charge to you.

By signing below you are personally accepting financial responsibility for all charges incurred and affirming that you will not seek reimbursement from Medicare.

______________________________ ________________ Signature Date