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Weight Loss Questionnaire

Describing My Current Climate

Beverage: I drink the following routinely

Typical Meals for me include: (if β€œnone”, please note that)





I have done the following weight loss programs before:




My Past Health History

Surgeries I have ever had include:

Prescription Medications I CURRENTLY take are:

Prescription Medications I CURRENTLY take are:

Weight Loss Program Policy & Agreement

*Please read the below information and sign prior to first visit

1. I understand that all weight loss sessions, whether in-person or via phone/tele-visit are considered a scheduled appointment time. I am aware that if I cannot make my scheduled appointment, it is my responsibility to call and cancel or reschedule. Patients should call the clinic if an appointment must be canceled or rescheduled at least 1 full business day prior to scheduled appointment.

2. As a client, I understand and agree that I am fully responsible for my physical, mental and emotional well-being during my calls, including my choices and decisions. I am aware that I can choose to discontinue coaching at any time.

3. I understand that weight loss program is a comprehensive process that may involve all areas of my life. Utilizing a whole person approach may include discussing subjects such as work, finances, health, relationships, education, spiritual and recreation. I acknowledge that deciding how to discuss these issues, incorporate coaching into those areas if needed, and implement my choices is exclusively my choice and personal responsibility.

4. I understand that coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association. I understand that coaching is NOT a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment. I further agree that I will not use it in place of any form of diagnosis, treatment or therapy.

5. I promise that if I am currently in therapy or otherwise under the care of a mental health professional, that I have consulted with the mental health care provider regarding the advisability of working with a health coach.

6. I understand that my information will be held as confidential and only shared as needed between health coach and provider for best health outcomes, unless I state otherwise, in writing, except as required by law.

7. I understand that coaching is not to be used as a substitute for professional advice by legal, medical, financial, business, spiritual or other qualified professionals. I will seek independent professional guidance for legal, medical, financial, business, spiritual or other matters. I understand that all decisions in these areas are exclusively mine and I acknowledge that my decisions and my actions regarding them are my sole responsibility.

Weight Loss Program Consent Form

authorize my Music City Primary Care physician(s), or advanced practice clinician(s) and/or whomever may be designated as the medical assistant(s), to help me in my weight reduction efforts. I understand that my program will consist of a prescribed diet, a regular exercise program, instruction in behavioral modification techniques, and may involve the use of appetite suppressant medications. Other treatment options may include a very low caloric diet, some form of fasting, or a protein supplemented diet. I further understand that if appetite suppressants are prescribed, they may be used for durations exceeding those recommended in the medication package insert. It has been explained to me to my complete satisfaction that these medications have been used safely and successfully in private medical practices as well as in academic centers for periods exceeding those recommended in the medication product literature.

I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. Risks associated with remaining overweight are tendencies to have high and increasing higher blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, sleep apnea, and sudden death. I understand that these risks may be modest if I am not significantly overweight, but will increase with additional weight gain.

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances made to me that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require drastic changes in eating habits and permanent changes in behavior to be treated successfully.


We understand that situations arise in which you must cancel your appointment. It is required that if you must cancel your appointment, you provide 24 hours notice. Providing advanced notice is a courtesy to your provider and allows another patient to be seen. Without notification, you are subject to a late cancellation fee or a no-show fee. We understand that special unavoidable circumstances may cause you to cancel within 24 hours prior to your appointment. Fees in this instance may be waived, but only with management approval.

I understand that office appointments which are canceled with less than 24 hours notice
are subject to a $35.00 cancellation fee.

I understand that if I no-show an appointment, I will be charged $35.00 to reschedule an
office appointment and to reschedule a procedure appointment.