FOYZ01 Weight Loss Form

Notice of Patient Privacy/Patient Consent Form

I understand that as part of my healthcare, the healthcare providers of 4 You LLC. originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals. 4 You LLC. Notice of Privacy Practices provides specific information and complete description of how my personal information may be used and disclosed. I understand that a copy of the Notice of Privacy Practices is available at the front desk and understand that I have the right to review the notice prior to signing this consent. I understand that 4 You LLC. reserves the right to change the Notice of Privacy Practices. Prior to implementation of the revised Notice of Privacy Practices, there vised Notice will be mailed to me if I provide my address below. I understand I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or healthcare operations and that 4 You LLC. is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that 4 You LLC. has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing. We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice, at any time (even if you have allowed us to communicate with you electronically). For more information about this notice or our privacy practices and policies, please contact the person listed at the end of this document.

NOTE: 4 You LLC. must obtain your written authorization to use your Private Health Information for any purpose other than treatment or billing. If you want 4 You LLC. to have access to disclose your Private Health Information to your spouse or any other person during your treatment, please sign below.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Date

MonthDayYear
Date

Medical Records Release Request
Date

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Requesting From - Medical Provider Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
I authorize the release of my medical records relevant to any treatment or copies of such and request that they be released to 4 You, LLC, Ashley Tincher, CNP, 1087 Mt.Vernon Avenue, Marion, Ohio 43302.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Should be Empty:

	Medical Problem	Diagnosis
1.
2.
3.
4.
5.

	Name and Strength	Purpose	Frequency Taken
1.
2.
3.
4.
5.
6.

	Year	Surgery and Reason	Hospital
1.
2.
3.
4.
5.

	Year	Reason	Hospital
1.
2.
3.
4.
5.

	Yes	No
Do you suffer from fatigue?
Do you turn to carbs for energy due to fatigue?
Have you ever been diagnosed with anemia?
Have you ever received a B12 shot before?

	Yes	No
Have you ever been prescribed medications for weight loss previously?
If so , were they effective?
Have you attempted diet and exercise before considering medication assisted weight loss?
Are you currently prescribed any stimulant, narcotic or other controlled medications?

	Age	Health Condition	Male or Female
Mother
Father
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Child 1
Child 2
Child 3
Child 4
Grandmother - Maternal
Grandfather - Maternal
Grandmother - Paternal
Grandfather - Paternal

	Yes	No
Is stress a major problem for you?
Do you feel depressed?
Do you panic when stressed?
Do you have problems with eating or your appetite?
Do you cry frequently?
Have you ever attempted suicide?
Have you ever seriously thought about hurting yourself?
Do you have trouble sleeping?
Have you ever been to a counselor?

	Yes	No
Heavy periods, irregularity, spotting, paid or discharge?
Are you pregnant or breastfeeding?
Gave you had a D&C, hysterectomy or Cesarean?
Any urinary tract, bladder or kidney infections within the last year?
Any blood in your urine?
Any problems with control of urine?
Any hot flashes or sweating at night?
Do you have menstrual tension, pain, bloating, irritability or other symptoms at or around the time of your period?
Experienced any recent breast tenderness, lumps or nipple discharge?

	Yes	No	Description of concerns
Skin
Chest/Heart
COVID 19
Head/Neck
Back
Weight
Ears
Intestinal
Energy Level
Nose
Bladder
Ability to sleep
Throat
Bowel
Lungs
Circulation
Other pain/discomfort