Transform your Life…

CLINIX HEALING CENTER

www.clinixusa.com

PH. # 303.721.9984

Clinix’s Medically

Assisted Weight

Loss Program

Transform your Life… CLINIX’s Medically Assisted

Weight Loss Program NAME: DATE: DATE OF BIRTH:

Clinix Healing Center 7030 S. Yosemite St

Centennial CO 80112

Ph # 303.721.9984

www.clinixusa.com

Transform your Life

Transform your Life: Weight Loss Program

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Medically Assisted Weight Loss Program

Contemplation

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Transform your Life: Weight Loss Program Visit Outline

How to schedule your visits:

On your first visit:

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On your first visit:

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On your first visit:

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Medical Evaluation with Bariatrician( 2 visits):

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Medically Assisted Weight Loss Program

Maintaining your weight loss program:

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Starting your weight loss program:

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Learn a little bit about Your Transformation Team!

Dr. Barclay Board Certified Bariatrician

Kim VanDriessche Nutrition Therapist

Ryan Johnson – Exercise Therapist

Carolyn Mellette – Family Nurse Practitioner

Medically Assisted Weight Loss Program

WHAT ARE YOUR PERSONAL GOALS?

Goals:

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“How can you transform

yourself from a caterpillar

to a butterfly?”

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Glucose

BUN (blood urea nitrogen)

Creatinine

Sodium

Potassium

Chloride

Carbon Dioxide (CO2)

Calcium

Medically Assisted Weight Loss Program

Phosphorus

Vitamin D

Protein

Albumin

Globulin

Bilirubin

Alkaline Phosphatase

AST, ALT and GGT

Lactate Dehydrogenase (LD or LDH)

Uric Acid

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Iron

Thyroid Hormone (Free T3, Free T4, TSH)

Total Cholesterol:

Total Cholesterol Level

Low Density Lipoprotein (LDL)

High Density Lipoprotein (HDL)

Triglycerides

Coronary Risk Ratio

Medically Assisted Weight Loss Program

BODY COMPOSITION

Your Body Mass Index

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Metabolic Evaluation

Medically Assisted Weight Loss Program

Resting Calories:

Lifestyle and Activity Calories:

Exercise Calories:

Total Calories Burned per Day:

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Are you an Apple or a Pear?

Medically Assisted Weight Loss Program

BEF

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Your Transformation GOALS

We want to set some goals for you! Now that you have your test results… decide

how you would like to transform your life. Do you want to lower cholesterol or

lose weight. Whatever your goal is… we would like to walk you through every

step of the way!

Weight:

Cholesterol:

LDL:

HDL:

Blood Sugar:

Hemoglobin

A1C:

Triglycerides:

Other:

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Track your Transformation

Date:

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Weight

Hip to Waist

Ratio

B.M.I.

Blood

Pressure

Pulse

Respirations

Lean Body

Mass

Fat Body

Mass

Medically Assisted Weight Loss Program

Track your Transformation

Date:

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Weight

Hip to Waist

Ratio

B.M.I.

Blood

Pressure

Pulse

Respirations

Lean Body

Mass

Fat Body

Mass

Medically Assisted Weight Loss Program

What is the difference between a serving size and a portion size?

A portion size is what we choose to eat at one sitting or what is served to us at a restaurant.

A serving size is the standardized amount that is used for foods and is what is taken into account on nutrition labels.

Most of us get confused between what a serving size is and what a portion size is.

Relating everyday items to a serving size helps us to remember what exactly a

serving size looks like!

Remember these tricks when you are trying to figure out what is considered a

serving!

4 dice = 1 oz. portion of cheese

A deck of cards = about 3-4 oz. of meat

A checkbook = 3 oz. of fish

A computer mouse = a medium sized potato

A baseball = 1 cup of fruit or vegetables

A computer mouse = ½ cup cooked rice or pasta

A ping-pong ball = 2 Tbsp. of peanut butter

A tennis ball= 8 oz yogurt, one cup of beans,

or one cup of dry cereal

Being able to estimate what an actual serving size looks like helps us to keep from overeating!

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4 dice = 1 oz. of cheese

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A computer mouse = a medium potato

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A deck of cards = about 3-4 oz. of meat

= A ping pong ball = 2 Tbsp. peanut butter

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Why is protein important for weight loss?

Quality protein in your diet is the single most important calorie that

influences your metabolic rate, therefore helping to increase weight loss.

Under most conditions, protein keeps you feeling fuller longer than carbohydrates. Several studies suggest that higher protein diets may increase total weight loss and help to increase the percentage of fat loss.

Protein is not only important for weight loss but it is a critical part of our diet. It helps us to maintain the health of our muscles and bones throughout our life! It is also very important in helping us maintain mobility as we age and in keeping our tissues healthy.

If you don’t get enough protein in your diet, all of your organs can be affected from the kidneys to the heart. The immune system also is affected and you are more likely to get sick and are at an increased risk for infections.

Examples of quality protein:

Poultry(Chicken, Turkey)

Fish

Lean Beef

Pork

Eggs

Tofu

Bison

Greek Yogurt

Cottage Cheese

Soy Products

Quality protein also helps you:

sustain muscle during weight loss

improve muscle fitness

improve immunity

improve antioxidant function

raise your HDL cholesterol

enhance insulin function

All of which contribute toward weight loss and helping to keep the weight off

for good!

Medically Assisted Weight Loss Program

Why are Nutri-Script products better? Your supplements are an important part of your weight loss program!

The products we use in our program are:

Nutri-Omega

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Nutri-D5000

Nutri-TLC

Did you know that deficiency in Vitamin D increases the

risk of bone loss, tooth detachment, neuromuscular

weakness, and colon/rectal cancer?

Nutri-TLC is designed to provide 100%

of the RDI of all vitamins.

Medically Assisted Weight Loss Program

Nutri-Glycemia

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CLINIX’s Medically Assisted Weight Loss Program

Activity Counseling

Activity and diet are the most important factors in achieving and

maintaining optimal health. One of the safest ways of becoming more

active is walking. No matter what shape you are in, walking gets you

moving more often and starts you on a path of healthy living.

Your Activity Counseling Sessions include:

Meet and Greet with

Exercise Therapist, Ryan Johnson - Short discussion about what to expect during activity counseling

and answering any questions that they may have about the

program.

On your 1st Activity Counseling Visit - Free Pedometer! – Pedometer functions will be reviewed and you

will be trained how to set and monitor your daily pedometer usage

and steps.

- Activity Counseling Assessment- An assessment will be performed

assessing activity history, basic aerobic capacity, core stability,

upper and lower body strength, endurance, and flexibility.

- Activity Log – You will be given a activity log to track your daily

pedometer steps and to monitor your daily activities.

On your 2nd Activity Counseling Visit - A Customized Physical Activity Program, in which we will discuss

specific goals, pedometer use, and activity journals.

- Pedometer goals set – Daily goals will be suited for you and your

weight loss target after you and your exercise therapist review your

activity log.

Monthly Follow-Up Visits - Update activity goals, progress with physical activities, and answer

any questions or concerns that you may have.

Your path to a better YOU!

Transform your Life

YOUR OWN THOUGHTS….

Use this page to write down how you are feeling, what you are thinking, or use it for anything that you choose.

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Transform your Life

Welcome to your new lifestyle…

How do I feel now that I have been successful at losing weight compared

to how I felt before I started the program?

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Now that I’ve lost weight, what am I going to do to keep it off? What

promise am I going to make to myself to make this happen?

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Medically Assisted Weight Loss Program

How am I going to avoid temptation?

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What eating habits did I have before I started this program that need to

be changed or eliminated? How am I going to do so?

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What other lifestyle changes can I make for myself to make me be an

overall healthier person?

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Medically Assisted Weight Loss Program

How Are You Transforming Your Life?

What part of the program did you find to be the most challenging?

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What part of the program did you have the most success with?

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Do you feel happier and/or healthier since beginning this program?

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How did this program transform your life?

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Do you feel that you would benefit from quarterly nutrition therapy visits?

NO YES

www.clinixusa.com

Medically Assisted Weight Loss Program

Bariatric Medical Progress Note

Please review and complete the form as well as sign and date.

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Medically Assisted Weight Loss Program

CLINIX Healing Center

7030 South Yosemite

Englewood, CO 80112

Phone: (303) 721-9984

FAX: (303) 267-7304

Off-Label use of Appetite Suppressants

PROCEDURE AND ALTERNATIVES:

I, _______________________ (patient or patient's guardian) authorize the bariatric physician and those designated the bariatric physician to assist me in my weight reduction efforts. I understand that my treatment may involve, but not be limited to the use of appetite suppressants for more than 12 weeks and, when indicated, in higher doses than indicated in the appetite suppressant labeling.

I have read and understand my doctor's statements that follow:

Medications, including the appetite suppressants, have labeling worked out between the maker of the medication and the Food and Drug Administration. This labeling contains, among other things, suggestions for using the medication. The appetite suppressant labeling suggestions are generally based on shorter-term studies (up to 12 weeks) using the dosages indicated in the labeling. As a bariatric physician, I have found the appetite suppressants helpful for periods far in excess of 12 weeks and, at times, in larger doses than those suggested in the labeling. As a physician, I am not required to use the medications the labeling suggests, but I do use the labeling as a source of information along with my own experience, the experience of my colleagues, recent longer term studies and recommendations of university-based investigators. Based on these, I have chosen, when indicated, to use the appetite suppressants for longer periods of time and, at times, in increased doses. Such usage has not been as systematically studied as that suggested in the labeling and it is possible, as with most other medications, that there could be serious side effects (as noted in II below). As a bariatric physician, I believe the probability of such side effects is, in some patients, outweighed by the benefits of the appetite suppressant use for longer periods of time and/or in increased doses. However, you must decide if you are willing to accept the risks of side effects, even if they might be serious, for the possible help that appetite suppressants used in this manner may give. I understand that it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible. I understand that the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand that my continuing to receive appetite-suppressing medication will be dependent on my progress in weight reduction and weight maintenance. I understand that there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced calorie-counting program or an exchange-eating program without the use of the appetite suppressant would likely prove successful, if followed, even though I would probably feel hungrier without the appetite suppressant.

RISKS OF PROPOSED TREATMENT

I give this authorization with the knowledge that the use of the appetite suppressants for more than 12 weeks or in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include: nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. These and other possible risks could, in some cases be serious or even fatal.

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RISKS ASSOCIATED WITH BEING OVERWEIGHT OR OBESE

I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies to high blood pressure, to diabetes, to heart attack and heart disease and to arthritis of the hips or other joints. I understand these risks may be modest if I am not very much overweight, but that these risks can go up significantly the more overweight I am. NO GUARANTEES

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all of my life if I am to remain successful. PATIENT'S CONSENT

I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking to my bariatric physician or the designated assistants.

Patient Name: Patient ID:

Patient Signature:

Date: __________

Witness Signature:

Date: __________

Provider Acknowledgement:

_____________________________ Date: __________

Medically Assisted Weight Loss Program

CLINIX Healing Center

7030 South Yosemite

Englewood, CO 80112

Phone: (303) 721-9984

FAX: (303) 267-7304

Use of Appetite Suppressants

PROCEDURE AND ALTERNATIVES

I, ________________________ (patient or patients guardian) authorize the bariatric physician and those designated to assist me in my weight reduction efforts. I understand that my treatment may involve, but not be limited to the use of appetite suppressant medications. What are diet pills?

Certain drugs have been found to reduce appetite and possibly increase the body’s use of calories. For some people, these drugs can be used to aid weight loss. Although amphetamines (speed) were once used for this purpose, amphetamines are no longer used. I understand that it is my responsibility to follow the instructions carefully and to report to the bariatric physician any significant medical problems that I think may be related to my weight control program as soon as reasonable possible. I understand that the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand that my continuing to receive appetite-suppressing medications will be dependent on my progress in weight reduction and in weight maintenance, and on my returning to this office on a regular basis for medical monitoring. I understand that I am forbidden by federal law to give or sell any medication prescribed to me to anyone else. I agree to abide by this restriction. I agree not to take any of these medications at higher dose or for longer than prescribed by the bariatric physician. I further understand that, according to federal law, I must be present personally each time my medication is dispensed. In other words, I may not send a friend or relative to pick up my medication for me. I understand that there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced calorie-counting program or an exchange-eating program without the use of the appetite suppressant would likely prove successful, if followed, even though I may feel hungrier without the appetite suppressant. RISKS OF PROPOSED TREATMENT I give this authorization with the knowledge that the use of appetite suppressants (diet pills) involves some

side effects and hazards. Besides reducing appetite, most of these drugs tend to have similar side effects. As with all medications, effects depend on an individual?s sensitivities as well as the dose taken. These and other side effects can be serious or even fatal:

Diet drugs can raise blood pressure and speed the heart rate, sometimes severely.

They may cause heart attacks and stroke.

They can over stimulate the brain, causing irritability, anxiety, panic disorder, sleeplessness or seizures.

They can also sedate the brain, causing drowsiness, memory loss and confusion.

They can cause migraine and severe mental illness, including psychosis.

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They can cause dry mouth, stomach, bowel and bladder problems, constipation, diarrhea, impotence, hives, sweating, eye irritation, muscle aches, numbness, chills, fever and many other symptoms.

They interact powerfully with certain other drugs. In combination with some medications (especially blood pressure medications, antidepressants, alcohol and anesthetics) they could cause sudden death.

They never be taken by children, by persons with glaucoma, or during pregnancy or nursing. There is a chance that these drugs could should be harmful to a fetus (although this is not known for sure).

There is a chance that some of these drugs may be habit-forming.

Researchers are investigating reports that some ? perhaps all ? of these medications may cause brain or nerve damage, even during short-term use. This has been seen in laboratory animals. Some researchers believe that while there may be some changes in brain cells, they don?t really cause any problems in humans. However, other researchers believe that the brain damage is real and serious. But no one really knows what happens with long-term use in humans.

Use of these drugs for more than three months is associated with an increase in the risk of primary pulmonary hypertension, a rare lung disorder which is often fatal. This disease occurs in about 1-2 people per million in the general population; however, primary pulmonary hypertension has been seen in 23-46 per million people who use diet pills.

It is possible that in the future, new hazards will be discovered that will create concern about your having taken diet medication. Keep this in mind before you decide to start.

We cannot predict what success you may have with diet medications.

RISKS ASSOCIATED WITH BEING OVERWEIGHT OR OBESE

I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies to high blood pressure, to diabetes, to heart attack and heart disease and to arthritis of the hips or other joints. I understand that these risks may be modest if I am not very much overweight, but that these risks can go up significantly the more overweight I am. NO GUARANTEES

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue watching my weight all of my life if I am to remain successful. PATIENTS CONSENT

I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding other treatments not involving appetite suppressants. WARNING

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTION WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THIS CONSENT FORM.

Patient Name: Patient ID:

Patient Signature:

Date: ___________

Witness Signature:

Date: ___________

Provider Acknowledgement:

______________________ Date: ___________