Health Questionnaire Form
|Female Client Only
you follow a particular diet ?
you gained/lost weight recently?
|What are the names of weight
loss programs or diets that you have tried?:
below warrants that I have completed this questionnaire
truthfully and accurately. My records will be
kept confidential and will only be shared with
the physicians and staff of SlimXpress ™ .
My written consent is required for any sharing
of information outside of SlimXpress ™ .
I understand that the staff and physicians of
SlimXpress ™ are providing services
to me related specifically for and only to the
issue of medically supervised weight loss and
that no offer of primary care services are included
in this program. The interview with the SlimXpress ™ physician is related only
to the area of medically supervised weight loss.
The doctor’s examination does not represent
a complete history and physical or any other
area of medical practice.
did you hear or learn about our SlimXpress ™ Program?
you know of anyone who has lost weight
on the SlimXpress ™ program?
read any of the book The Weight Loss Cure
by Kevin Trudeau
read Pounds and Inches. The New Approach
to Obesity by Dr. Simeons?
of Receipt of Statement of Privacy Practices
that I have received a copy of the Statement
of Privacy Practices for SlimXpress ™ . The Statement of Privacy Practices describes
the types of uses and disclosures of my protected
health information that might occur in my treatment,
payment for services, or in the performance
of office operations. The Statement of Privacy
Practices also describes my rights and the responsibilities
and duties of this office with respect to my
protected health information. The Statement
of Privacy Practices is also posted in the facility.
SlimXpress ™ reserves the
right to change the privacy practices that are
describes in the Statement of Privacy Practices.
If privacy practices change, I will be offered
a copy of the revised Statement of Privacy Practices
at the time of my first visit after the revisions
become effective. I may also obtain a revised
Statement of Privacy Practices by requesting
that one be mailed to me.
to the allowable disclosure described in the
Statement of Privacy Practices, I hereby specifically
authorize disclosure of my protected healthcare
information to the persons indicated below.
For Treatment With hCG and/or Lipotropics
initial each section to indicate that you understand
Do not initial if you desire more information.
The SlimXpress ™ Protocol is for the
reduction of excessive weight. A key component
of the protocol is the use of hCG (Human Chorionic
Gonadotropin). The hCG will either be administered
orally or through an injection. The use of HCG
for weight loss was first identified by A.T.W.
Simeons, M.D. in the 1960s. The publication
of his book, Pounds and Inches. The New Approach
To Obesity in 1969 has made his protocol available
globally. The therapeutic protocol used in this
program does not exceed the hCG dosing recommended
by Dr. Simeons. This protocol does include dramatic
during the rapid weight loss phase.
The SlimXpress ™ protocol is designed
to yield rapid weight loss, often reported at
1/2 to 1 pound per day during the weight loss
phase of the program. Our protocol includes
several features to help assure the maintenance
of lean muscle mass during the rapid weight
By bringing your weight into a more healthy
range (BMI of 18 to 23 for men and 20 to 25
for women) the benefit would include improvement
in the body’s maximum functioning with
a well known decrease in many health concerns
including, but not limited to, risks of developing
cancer, diabetes, heart disease and high blood
Possible side-effects of hCG may include
transient headache or allergic reaction. When
an injection is administered there is always
a risk of infection at the injection site. The
use of hCG for other medical treatments is at
a much higher dosage (as is used during fertility
treatment for both males and females). There
is no evidence that the use of the small doses
in Dr. Simeons protocol has any effect on increasing
or decreasing fertility.
For clients with high blood pressure who are
on medication there is always a concern that
they may require a decrease in the dosage of
medication as they lose weight because of a
natural improvement of blood pressure. For clients
with diabetes who are on medication or insulin
there is always a concern that they may require
a decrease in the dosage of medication as they
lose weight because of a natural improvement
in blood sugar levels. For clients who are prone
to low blood sugar (hypoglycemia) there is a
risk that their blood sugar may become low at
different times during the day.
and Breastfeeding (female client)
The use of hCG in the doses used in our protocol
will not have any known effect on the client’s
ability to become pregnant. We do not start
treatment on a pregnant woman. If a client becomes
pregnant during the treatment she is to notify
our office and discontinue treatment during
pregnancy and breastfeeding. Treatment will
not be started while a woman is breastfeeding
By signing this consent I assert that I am not
pregnant or breastfeeding.
The FDA has not approved hCG for weight loss;
it’s use for weight loss is consider an
“off label” application. The use
of hCG has not been demonstrated to be effective
adjunctive therapy in the treatment of obesity.
There is no substantial evidence that it increases
weight loss beyond that resulting from caloric
restriction, that it causes a more attractive
or “normal” distribution of fat,
or that it decreases the hunger and discomfort
associated with calorie restricted diets.
The client chooses which delivery system of
hCG they would prefer: by mouth at home or by
subcutaneous injection at home. If the client
chooses to visit a clinic location, the hcg
may be administered by an intramuscular injection.
When the hCG is given by intramuscular injection
at the clinic it is mixed with a form of Vitamin
B12 to help assure slow release over several
days. In addition, at the clinic locations,
the doctor may recommend the use of additional
nutritional substances given intramuscularly
to help further stimulate fat metabolism. The
additional substances may include B vitamins,
amino acids, essential and non-essential nutrients
that work in conjunction with the hormone, hCG.
have carefully read and initialed the preceding
sections of this consent for treatment with
hCG. I understand that the use of hCG for weight
loss is not approved by the Food & Drug
Adminstration. My questions have been answered
satisfactorily by the doctor and doctor’s
associates. With this knowledge, I voluntarily
consent to the use of hCG. I realize that the
doctor nor any personnel of SlimXpress ™ has made no absolute guarantees to me regarding
cure or improvement of my condition. I understand
that I am free to discontinue participation
in this treatment program at any time. I agree
to the use of arbitration to settle legal controversies
that may arise as part of my treatment program.
Following Disclaimer is required by
|hCG has not been demonstrated
to be effective adjunctive therapy in
the treatment of obesity. There is no
substantial evidence that it increases
weight loss beyond that resulting from
caloric restriction, that it causes a
more attractive or "normal"
distribution of fat, or that it decreases
the hunger and discomfort associated with
calorie- restricted diets. The FDA has
not approved hCG for weight loss.
of Privacy Practices - SlimXpress ™
|Our office is dedicated to
protect the privacy rights of our clients and
the confidential information entrusted to us.
The commitment of each employee to ensure that
your health information is never compromised
is a principle concept of our practice. We may,
from time to time, amend our privacy policies
and practices but will always inform you of
any changes that might affect your rights.
Your Personal Healthcare Information
|We use and disclose the information
we collect from you only as allowed by the Health
Insurance Probability and Accountability Act
and the state of Washington. This personal health
information will never be otherwise given to
anyone, even family members, without your written
consent. You, of course, may give written authorization
for us to disclose your information to anyone
you choose, for any purpose.
Our offices and electronic systems are secure
from unauthorized access and our employees are
trained to make certain that the confidentiality
of your records is always protected. Our privacy
policy and practices apply to all former, current,
and future cliients, so you can be confident
that your protected health information will
never be improperly disclosed or released.
Protected Health Information
|We will only request
personal information needed to provide
our standard of quality healthcare, implement
payment activities, conduct normal healthcare
practice operations, and comply with the
law. This may include your name, address,
telephone number(s), social security #,
employment data, medical history, health
records, etc.. While most of the information
will be collected from you, we may obtain
information from third parties if it is
deemed necessary. Regardless of the source,
your personal information will always
be protected to the full extent of the
of your Protected Health Information
| As stated above, we may disclose
information as required by law. We are obligated
to provide information to law enforcement and
governmental official under certain circumstances.
We will not use your information for marketing
purposes without your written consent.
We may use and/or disclose your health information
to communicate reminders about your appointments
including voicemail/answering machine messages,
postcards, newsletters and special events.
|You have the right to request
copies of your healthcare information; to request
copies in various formats; and to request a
list of instances in which we, or our business
associates, have disclosed your protected information
for used other than stated above. All such requests
must be in writing. We may charge you for copies
in an amount allowed by law. If you believe
your rights have been violated, we urge you
to notify us immediately. You can also notify
the U.S. Department of Health and Human Services.
We thank you for being a patient at our office.
Please let us know if you have any questions
concerning your privacy rights and the protection
of your personal health information.
If you would like to receive e-mails from SlimXpress ™ about information on special
saving on products or services or new services
being offered please fill out the information
|We look forward
in seeing you as a client/patient of SlimXpress ™ .
these weight reduction treatments include
oral HCG or an injection of HCG, a drug which
has not been approved by the food and drug
administration as safe and effective in the
treatment of obesity or weight control. There
is no substantial evidence that HCG increases
weight loss beyond that resulting from caloric
restriction, that it causes a more attractive
or “normal” distribution of fat, or that it
decreases the hunger and discomfort associated
with calorie-restrictive diets.