JOHNS HOPKINS INSTITUTIONS
-Johns Hopkins Hospital
-Johns Hopkins Bayview Medical Center
-Howard County General Hospital
-Johns Hopkins Community Physicians
-Johns Hospital Home Care Group
-Ophthalmology Associates
-The Center of Ambulatory Services
-Howard County Neonatal Services
-Frederick County Neonatal Services
-Johns Hopkins Emergency Medical Services
-Designated health care components of The John Hopkins University
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received a copy of the Johns Hopkins Notice of Privacy Practices.
Patient Name: ___________________________________________________________
(first)
(m initial)
(last)
Signature: ___________________________________ Date: _____________________
Medical Record #: ________________________________________________________
SSN: (last four#s)_____________________________ Birth Date: _________________
For personal Representatives, please provide the following and attach contact information.
I _____________________________________________represent that I am the healthcare
agent/guardian/surrogate/parent of the patient named above.
Personal Representative Signature: ____________________________________________
If you are the healthcare agent or guardian, please provide proof of your authority to act on behalf of
the patient.
NPPack.doc THE NOTICE IS EFFECTIVE APRIL 14, 2003 AND SUPERCEDES EARLIER VERSIONS
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Consent to Participate In
The Johns Hopkins Weight Management Center's Weight Loss Program
There are two Weight Loss Programs the first of which is the Fast Track/Quick Start Program that employs a mealreplacement-based diet for the purpose of weight reduction. The program is medically supervised and designed for
individuals with a body mass index > 30. The program uses food-based meal replacements for up to 16 weeks or
longer if medically appropriate. The food-based meal replacements provide calories, protein, vitamins, and
minerals. Weekly medical evaluation is required during treatment. In addition, behavioral modification and
nutrition education sessions are required.
The second program, the Essentials Program, is more flexible, food-based, and designed for individuals with a
body mass index >25. Behavior modification and nutrition education sessions are required.
The clinical staff of the Johns Hopkins Weight Management Center consists of physicians, exercise physiologists,
behavioral therapists, and registered dietitians.
Benefits:
When followed properly, the programs enable maximum weight loss to occur under medically-controlled
conditions. If new exercise patterns and dietary habits are continued, the risk of significant weight regain is
reduced. Benefits of weight reduction may include improved health, both physiological and psychological, and an
enhanced quality of life.
Risks:
As with most forms of medical therapy and exercise programs, there is a risk of experiencing adverse side effects.
Symptoms are generally mild and transient and appear during the first several days or weeks of treatment. These
symptoms may include headache, dry skin, brittle nails, reduced tolerance to cold, constipation, diarrhea, temporary
hair loss, fruity smell or “bad” breath, fatigue, light-headedness or dizziness, muscle cramps in lower legs, missed
or late menstrual periods, increased fertility, and recurrence or development of gout. There is also an increased risk
of developing gallstones, or having existing gallstones become symptomatic. I also understand that my
participation in recommended exercise activities and/or use of exercise equipment may result in injury or illness
including, but not limited to bodily injury, muscle, tendon, or ligament strains or sprains, fractures, partial and/or
total paralysis, death, or other injuries that could cause serious disability.
I understand that, by my participation in the Johns Hopkins Weight Management Center’s Weight Loss Programs
and recommended physical activities, I, on behalf of myself, my personal representatives and my heirs, assume all
risks and dangers and all responsibility for any losses and/or damages incurred as a participant, and voluntarily
agree to release, waive, discharge and hold harmless the Johns Hopkins Weight Management Center, and its
employees and agents, from any and all claims, actions or losses for bodily injury, property damage, wrongful
death, loss of services or otherwise which may arise out of my participation in a weight loss program provided by
the Johns Hopkins Weight Management Center, and participation in recommended physical activities.
I have read and understand the above information and I have had an opportunity to ask questions and have had my
questions answered to my satisfaction.
_________________________________________
Patient or Authorized Health Care Decision Maker
_______________________
Date
________________________________________
Health Care Provider obtaining consent
_______________________
Date
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Client Responsibilities/Consent for Evaluation and Treatment
I understand that it is my responsibility to complete all required assessments, attend treatment sessions as
recommended by the clinical staff, and to fulfill all personal and financial obligations of the program.
I hereby authorize and direct the staff of the Johns Hopkins Weight Management Center to provide
multidisciplinary weight management evaluation and treatment. Multidisciplinary treatment includes
nutritional, psychological, and exercise assessments and follow-up with medical monitoring, as
appropriate.
I am advised that no guarantee can be made concerning the expected results of a weight management
program.
I understand that I am free to discontinue the program at any time, either verbally or in writing, without
fear of prejudice in other treatment that I may receive at Johns Hopkins. If all financial obligations have
been met, I am free to re-enter the program at any time. However, after an absence of three months or
more, one or more re-assessments may be required as deemed necessary by the clinical staff.
I understand that components or products used in the program may be changed, but that I will be
reasonably advised of all changes.
I understand that 24 hour emergency care is not available. Therefore, in the event that I experience a
medical or psychological emergency, I am aware that I should call “911” and/or go to a hospital
emergency room.
I understand that the information that I provide during individual assessments and subsequent sessions
may, if necessary, be discussed with other members of the clinical staff. All such information is held in
the strictest confidence by all team members. Limits to confidentiality include intent to harm myself or
another and current or past harm to a minor which must be reported to child protective services.
Information disclosed to any member of the clinical staff may become part of my medical file.
I understand that any appointment must be cancelled at least 24 hours in advance to avoid charge
for the appointment time. Additionally, the full scheduled time will be charged if I arrive late for an
appointment. Initial assessments and consults that are cancelled or missed without at least 24 hours notice
will not be rescheduled without advance payment of the cost of the scheduled assessment and/or consult
appointment. In the event of severe inclement weather, clients will not be billed for missed appointments.
I have read the above policy, schedule of fees, and agree to the terms.
_________________________________________
Patient or Authorized Health Care Decision Maker
_______________________
Date
_________________________________________
Health Care Provider obtaining consent
_______________________
Date
Rev. September 26, 2013
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Page 1 of 1
Johns Hopkins Weight Management Center
Client Data Base
The information in this questionnaire will be reviewed by members of our clinical staff (physicians, dietitians,
psychologists, exercise physiologists). Please be assured that all information that you provide will be regarded
as confidential, and will only be available to the professionals on your treatment team.
Please allow about 1 hour to complete this questionnaire. It is very important that everything is completed
PRIOR to arriving for your first assessment.
An incomplete application is likely to delay your appointment and your treatment with us.
Full Name _________________________________________________________________________________
Address ___________________________________________________________________________________
City ______________________________
State __________
Zip ___________
Phone (Cell) ______________________
(Home/Work) __________________________
Date of Birth _______________________
Age _______
Today’s Date ______________________
Social Security # (last 4 digits) __________
Sex ____ Race _______
Email Address (please print)______________________________________________________________
Current Height _______ Weight ________lbs Weight 1 year ago________
Lowest adult weight ______ At what age? _______ How long maintained? ________
Lowest adult weight maintained for >1 year _______ At what age? _______
What is your personal goal weight at this time? ________ lbs
Family History of Overweight (use back of page if needed):
Relative
Age (or age
at death)
Living
(Y/N)
Degree of Overweight
None
Slight (5-15 lbs)
Moderate (16-49 lbs)
Very (50+ lbs)
Father
Mother
Brother – oldest
2nd oldest
3rd oldest
Sister – oldest
2nd oldest
3rd oldest
Father’s mother
Father’s father
Mother’s mother
Mother’s father
Spouse/ partner
For each time period, please record your maximum weight. If you cannot remember, make your best guess
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and mark “G.” Please note any events related to your weight during this period (i.e., in college, pregnant, end
of relationship).
Please record your major diets which resulted in a weight loss of 10 lbs. or more.
Maximum
Weight
Age
Events Related to Weight Gain
5-10
11-15
16-20
21-25
26-30
31-35
36-40
41-50
51-60
60+
DIET
AGE
WEIGHT AT START
OF DIET
POUNDS
LOST
COMMENTS
1
2
3
4
5
6
How many times have you intentionally lost 20 lbs. or more and then gained it back?
Never ____ Once or twice ____ 3-4 times ____ 5+ times ____
If you have been pregnant, please tell us about weight gain you experienced (use back of page if needed).
Age
Weight at start of
pregnancy
Pounds gained
during pregnancy
Lowest weight in year
post-delivery
Check if you (or any family member) have or have had any of the following. Please add detail as needed on the
back of this sheet for any “yes” answers that apply to you (not to relatives).
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Condition
High Blood Pressure
Heart Disease
Yellowing
Thyroid Disease
Kidney Disease
Shortness of Breath
Stroke
Swelling of feet
Frequent headaches
Seizures or epilepsy
Psychological difficulties
Psychiatric conditions
Depression
Anxiety or panic attacks
Hemorrhoids
Asthma
Phlebitis
Fainting/ lightheaded
Diabetes
Loss of muscle strength
High cholesterol
Other (list)
You
Relative
(List Who)
Condition
You
Relative
(List Who)
Gallbladder disease
Liver disease
Chest pain
Irregular heartbeat
Alcoholism or drug abuse
Arthritis
Cancer
Anemia
Low back pain
Gout
Ulcers
Constipation
Chronic diarrhea
Heartburn
Gas/ bloating
Chronic cough
Allergies
Dizziness
Frequent nausea
Numbness in hands/ feet
Sleep difficulties
Past Hospitalizations (include psychiatric, as well as operations):
Year
Reason
Current Medications: (list all, including name, frequency, and dose; include hormones and birth control pills).
__________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Please list any medication allergies: _________________________________________________________
1)
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During the past 6 months, did you often eat within any
Yes _____ No _____
two hour period what most people would regard as an
unusually large amount of food?
Complete questions a through h only if you answered yes to the previous question.
a. During the times when you ate this way, did you often feel
you couldn’t stop eating or control what or how much you
were eating?
Yes _____ No _____
b. During the past 6 months, how often have you eaten this way (large amounts of food along with the
feeling that your eating was out of control)?
Less than 1 day/wk ___1 day/wk ___ 2-3 days/wk ___4-5 days/wk ___ 6-7 days/wk _____
c. Did you experience any of the following during these occasions?
Y
N
Eating more rapidly than usual
Y
N
Eating alone because of embarrassment
about amount of food eaten
Eating until uncomfortably full
Feeling disgusted, depressed or guilty after
overeating
Eating when not physically hungry
d. What time of day did this type of eating occur?
Morning (8 am to noon) _____ Early afternoon (noon to 4 pm) _____
Late afternoon (4-7 pm) _____ Evening (7-10 pm) _____ Night (after 10 pm) _____
e. Approximately how long did the episode last (from the time you started eating to when you stopped
and didn’t eat again for at least 2 hours)? _______ hours _______minutes
f.
At the time the episode started, how long had it been since you had previously finished eating a meal or
a snack? __________ hours __________minutes
g. Please list everything you might have eaten or drank during the episode. Include brand names where
possible, and your best estimate of amounts. Example: 7 ounces of Lays cheddar cheese potato chips; 2
cups of Lucerne chocolate ice cream with 3 tablespoons of hot fudge; 1 16-ounce bottle of Coca-cola; 1
½ sandwich with ham, cheese, lettuce and tomato, mayonnaise and mustard.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
h. How old were you when you first had times when you ate large amounts of food and felt that your
eating was out of control? (If not sure, give best guess) _____years
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In general, during the past 6 months, how important has your weight or shape been in how you feel about
yourself as a person (as compared to other aspects of your life, such as how you do at work, as a parent, or
how you get along with other people)?
Y
N
Weight and shape were not very important
Weight and shape played a part in how I felt about myself
Weight and shape were among the main things that affected how I felt about myself
Weight and shape were the most important factors in how I felt about myself
During the past 6 months, how upset were you by overeating (eating more than you think is best for you?)
Not at all _____ Slightly ______ Moderately _____ Greatly _____ Extremely _____
Have you attempted any of the following behaviors in order to prevent gaining weight?
Number of times/wk
Y
N
<1
1
2-3
4-5
Taking more than twice the recommended dose of diet pills
Taking more than twice the recommended dose of laxatives
Taking more than twice the recommended dose of diuretics
Vomiting after eating
Abstaining from food for more than 24 hours
Exercising more than an hour
Do you smoke cigarettes? Yes _____ No _____ If yes, # per day _____ # of years _____
Do you drink alcohol? Yes _____ No _____
If yes, type and amount of alcohol per week ______________________________________________
Do you gamble? Yes ___ No ___ If so, how often?__________________________________________
Does the amount of shopping you do create a problem for you (financial, personal, etc.)? _________
Do you have any compulsive behaviors? __________________________________________________
Have you every participated in counseling or psychotherapy?
Yes _____ No _____
If yes, type: Individual _______ Family ________ Couples ________ Substance abuse _________
Please describe when, with whom, and for what reason: _____________________________________
____________________________________________________________________________________
Have you ever been the victim of abuse (physical, emotional, or sexual)? Yes _____ No _____
Marital or Relationship Status ________ Satisfaction with relationship right now _________________
Number of children and ages ___________________________________________________________
Highest grade/college year completed ______________________________________________________
Occupation ______________________ What hours do you usually work? ___________________
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6-7
How long have you worked there? _________yrs.
Is your job satisfying?____________________
Has your weight caused you problems at work (please explain) ____________________________
_________________________________________________________________________________
Has your weight caused you problems at home (please explain) ____________________________
_________________________________________________________________________________
What are your hobbies and how do you spend your free time? ______________________________
__________________________________________________________________________________
Describe a typical weekend:
__________________________________________________________________________________
Is your family supportive of your weight loss efforts? _______ If yes, how?____________________
__________________________________________________________________________________
Is anyone likely to sabotage your efforts? _______________ If yes, how? _____________________
__________________________________________________________________________________
Have any of the following contributed to your weight problems?
Y
N
Y
Stress
Sight and smell of food
Anger/Frustration
Eating in restaurants
Boredom
Poor planning
Happiness
Second helpings
Food as reward
Frequent snacking
Being with others (co-workers,
Holidays
N
celebrations)
Genetic history
Sedentary lifestyle
What does your hunger feel like? _________________________________________________________
How many times a day do you feel hungry? ________________________________________________
What time of day are you most hungry? ___________________________________________________
How many times do you snack per day? ____________________________________________________
How many meals do you eat per day?__________________________________________________ ____
How often do you eat breakfast? _______ What? _____________________________________________
______________________________________________________________________________________
Do you eat before going to bed? _______ What? ______________________________________________
______________________________________________________________________________________
What food habits would you like to change? _________________________________________________
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______________________________________________________________________________________
Who plans meals? _______________ Who cooks? ________________ Who shops? ___________
Which foods do you crave the most? __________________________________________________
________________________________________________________________________________
Do you eat while watching TV? _____ What do you eat? _________________________________
________________________________________________________________________________
Time spent watching TV? _____hrs/d Time of day ______Ounces of caffeinated beverages/d_____
How often do you eat at:
2-3
times/d
1
time/d
2-3
times/wk
1
time/wk
2-3
times/ mo
Fast food restaurants
Vending machines
Cafeterias
Hot dog/ food stands
Full service restaurants
Other
_______________________
Please indicate if you are currently experiencing stress in your life related to the following events:
Y N
Y
Work or possible job change
Children (birth, parenting issues, etc)
Relationships (marriage, divorce, end of
Financial difficulties
N
relationship
Beginning/ending college
Death of friend or relative
Moving
Other_____________________________
Are you planning any major life changes in the next year?
Yes _____ No _____
If yes, what? _________________________________________________________________________________
What is the most significant source of stress at this time? ____________________________________________
What are you doing about it? ___________________________________________________________________
____________________________________________________________________________________________
What is one thing in your life you would like to accomplish/complete and why? (other than to lose weight)
____________________________________________________________________________________________
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____________________________________________________________________________________________
Think back on other weight loss attempts. How are you most likely to sabotage your efforts, both short-term
and long-term?
____________________________________________________________________________________________
Is there any additional information that would be helpful to us to know when developing your individualized
weight management plan?
___________________________________________________________________________________________
What are your current activities? (type, frequency, duration, length of consistency, level of enjoyment):
____________________
What activities have you done in the past? (type, frequency, duration, length of consistency, level of
enjoyment, reason for stopping):
___
___
Days per week you are willing to devote to exercise ________________________________________________
Time of day you intend to exercise ______________________________________________________________
Amount of time available for this session _________________________________________________________
Would you rather do all of your exercise in one session or split it up throughout the day?
___________________________________________________________________________________________
Would you rather exercise solo, with a partner, in a group setting or with a trainer?
____________________________________________________________________________________________
Would you rather exercise at home, at a health club, at work or outside? ______________________
____________________________________________________________________________________________
What do you see getting in the way of your exercise time? __________________________________________
_____________________________________________________________________________________
Resources: (Please specify)
Y
11
N
Y
N
Health club membership
Trails/parks near home
Exercise videos
High schools/colleges near home
Exercise equipment
Personal trainer
Other exercise resources available not mentioned above?____________________________________________
What do you feel you are gaining from being physically active (besides losing weight)? __________________
___________________________________________________________________________________________
What type of physical activity is fun or enjoyable to you? (hiking, shopping, playing with your kids, etc.)
______________
_____________________________________________________________________________________
What was the last positive experience you had while being physically active? ___________________________
____________________________________________________________________________________________
What made this experience positive? _____________________________________________________________
____________________________________________________________________________________________
What are your personal exercise goals? ___________________________________________________________
____________________________________________________________________________________________
Does your work schedule vary week to week?
Yes___No___
Is your typical work day mostly sedentary?
Yes___No___
Is there opportunity to get up and move around at work?
Yes___No___
If you had to estimate all the activity you do throughout the day, how many minutes of activity do you
accumulate? ______ (Includes taking stairs, walking to and from your car, rooms, etc.)
Are the following available at your workplace?
Stairs _______ Hallways _______ Privacy _______ Safe neighborhood/ grounds _____
Fitness center _____ Other ____________________________________________________________________
Do you experience any muscle or joint pain? If so, please explain.
____________________________________________________________________________________________
Have you had any injuries/ surgeries that inhibit exercise? If so, please explain.
____________________________________________________________________________________________
Are you physically limited in any way? ____________________________________________________________
Interests: (Please circle all that are interesting to you)
Yoga
Dance
Free weights
Tennis
Pilates
Step aerobics
Weight machines
Competitive sport
Outdoor walk/ jog
Aerobics
Resistance bands
Outdoor cycling
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Treadmill walk/ jog
Video tapes
Calisthenics
Exercise ball
Elliptical
Group classes
Personal training
Hiking
Stationary bike
Seated exercise
Swim activities
Other _____________
HEALTH CARE PROVIDER INFORMATION
Primary care physician
Full Name:___________________________________________________________
Address:____________________________________________________________
Phone Number: ______________________________________________________
Additional care provider(s)
Full Name:___________________________________________________________
Address:____________________________________________________________
Phone Number: ______________________________________________________
Full Name:__________________________________________________________
Address:____________________________________________________________
Phone Number: ______________________________________________________
EMPLOYMENT INFORMATION
Occupation: ________________________________________________________
Employer: __________________________________________________________
Address: ___________________________________________________________
Policy Number (for Hopkins employees only)______________________________
EMERGENCY CONTACT
Name: _____________________________________________________________
Phone Number: _____________________Relationship:______________________
PHARMACY USED FOR PRESCRIPTION MEDICATIONS
Name: _____________________________________________________________
Address: ____________________________________________________________
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Phone Number: _________________________________________________________________
Client Name______________________________________________________________________
Thank you for taking the time to provide this important information.
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