‘Getting Started’ - Brevard Florida Health Insurance · PDF fileMIND DIET EERCISE BEYND ‘Getting Started’ This packet contains the following important information to assist

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‘Getting Started’This packet contains the following important information to assist you in getting started:

▶ Free Surgical Weight Loss Seminar

▶ ‘Getting Started’ What to Do Next

▶ Bariatric Surgery Information Sheet

▶ Surgical Weight Loss Support Group

▶ Behavior Modification Techniques

▶ Pre-Surgery Diet Practice Tips

▶ Bariatric Surgery Comparison

▶ Co-Morbidity Reduction After Bariatric Surgery

▶ BMI vs Mortality

▶ Long-Term Survival

▶ Insurance Benefit Worksheet*

▶ Patient Health History Form*

▶ Diet History Form*

▶ Seminar Questionnaire*

* Please fill out and return

110 LBS. DOWN

Frank: 110+ LBS. DOWNNewFit Patient

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Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery

Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com

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Free Surgical Weight-Loss SeminarWe’re glad you are here!

▶ Free NewFit Bariatric Weight-Loss Seminar

▶ Free NewFit Bariatric Weight-Loss Support Group

▶ No Administrative Fees

In addition, our NewFit Bariatric Program Members will be offered Health First Pro-Health & Fitness Center:

▶ Waived enrollment fee (up to $100 value),

plus $35 per month reduced membership

fee prior to surgery

▶ FREE 3-month membership post-surgery

upon receipt of medical clearance from

the Program Member’s NewFit physician

Please remember to fill out the Insurance Benefit Worksheet and the Seminar Questionnaire and turn in at the end of the seminar, and receive your complimentary Health First Pro-Health & Fitness Center 1-day pass. Thank you!

Carol: 87+ LBS. DOWNNewFit Patient

87 LBS. DOWN

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‘Getting Started’ What to Do Next!Check off as you complete each task!

Attend NewFit surgical weight loss seminar. Be sure to fill out the insurance benefit worksheet in your folder and turn it in.

The NewFit office will call to discuss your insurance benefits or self-pay options.

Attend office consultation.

Complete 3 to 6-month physician-supervised weight loss visits with your surgeon IF required by your insurance company.

Pre-op nutrition evaluation. Date and time to be scheduled at initial appointment.

Study your “Nutritional Guidelines” book, which explains the pre-/post-op diet requirements and what eating will be like after surgery. (You will receive this at your nutrition appointment.)

Exercise physology evaluation. Date and time to be scheduled at initial appointment.

Pre-op psychological evaluation. Refer to list provided. (To be scheduled by patient.)

Attend Pre-op education class to be scheduled at initial appointment.

Once we have all required documentation we will obtain insurance authorization from your insurance company or arrange your payment if you are self-funding your surgery.

Attend pre-op appt. (This is scheduled after your authorization is approved.)

Attend Support Group meetings a minimum of one time before surgery.

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▶ Psychology Associates of Brevard Dr. Robert Shapiro, Ph.D. & Kelly Jo Kaye, LMHC

Insurances accepted: Aetna, BCBS, Cigna, HFHP, Magellan, Medicare, Tricare, & UHC

6767 N Wickham Road, Suite 306, Melbourne, FL 32940 321.751.1925

▶ Dr. Wanda Bethea, Ph.D. Insurances accepted: Cigna, HFHP, Magellan & Tricare

405 E. Strawbridge Avenue, Melbourne, FL 32901 321.724.6177

▶ Dr. William Eyring, Ph.D. Merritt Island location: Tuesday, Wednesday, & Thursday

Insurances accepted: Aetna, BCBS, Cigna, HFHP, Magellan, Medicare & Tricare

1395 N. Courtenay Parkway, Merritt Island, FL 32953 321.459.1003

▶ Dr. Robert Lehton, Ph.D. Insurances accepted: BCBS, Aetna, Cigna, HFHP, Magellan, Medicare & Tricare

3000 N Atlantic Ave, #102, Cocoa Beach, FL 32931 321.784.5367

▶ Dr. Stephen D. Cotton, MSW, Ph.D. Insurances accepted: BCBS, HFHP, Magellan, Medicare & Tricare

2123 Franklin Drive NE, Palm Bay, FL 32905 321.724.1614

Pre-Surgery Nutrition/ Dietician EvaluationEvery patient needs a pre-op nutrition evaluation/education sessions with our dietician. Our office will arrange this appointment after your initial office consultation. Insurance may not cover the cost of this appointment. If it is not a covered benefit, you will be responsible for payment at a self-pay rate PRIOR to the

date of service.

Exercise Physiology EvaluationNewFit will provide our members the opportunity to meet with an Exercise Trainer for evaluation and goal setting for activity enhancement. Our office will arrange this appointment after your initial office consultation.

Psychological EvaluationIt is your responsibility to make arrangements for a psychiatric/psychological evaluation.

Below are some recommendations. A referral cannot be sent for you. We do recommend that you come in for your office consultation FIRST BEFORE scheduling/attending your psych evaluation.

Bariatric Pre-Surgery Information Sheet

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Surgical Weight Loss Support GroupStart today!

FocusFor patients who have had bariatric surgery or are considering bariatric surgery (Lap-Band, Sleeve Gastrectomy, Gastric Bypass). Feel free to bring a family member or friend with you.

Support Group Leaders ▶ Michele Pineault, RN, Bariatric Coordinator

Office: 321.434.9476 Mobile: 321.412.8252 Email: [email protected]

▶ Jessica Miller, LD RD Office: 321.434.9408 Email: [email protected]

Location/Date/Time ▶ Viera Hospital

(Pro-Health & Fitness Center Classroom)

8705 N. Wickham Road, Viera, FL 32940 Meets 2nd Monday of every month at 6 pm

▶ Palm Bay Hospital (Cafeteria Private Dining Room)

1421 Malabar Road NE, Palm Bay, FL 32907 Meets 4th Monday of every month at 6 pm

625 LBS down & counting

–Real Patients

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Behavior Modification TechniquesFor before and after surgery!

▶ Do not eat in front of TV.

▶ Do not read while eating.

▶ Pre-portion your food and put the box or package away.

▶ Keep tempting foods out of the house.

▶ Do not go to the grocery store hungry.

▶ Make a shopping list.

▶ Use smaller plates, bowls, and utensils.

▶ Keep healthy foods available.

▶ Focus on activities other than eating.

▶ Brush your teeth after every meal if feeling the desire to eat.

▶ Do not stand or eat at the food table at parties.

▶ Offer to bring a healthy food item to parties.

▶ Park your car far away from your destination.

▶ Get up to change the TV channel instead of using the remote control.

▶ Take the stairs instead of the elevator.

▶ Keep a food and exercise diary/journal.

▶ Begin some form of exercise or activity.

▶ If you feel hungry after eating or between meals, chew sugarless gum.

180 LBS. DOWN

Nancy: 180+ LBS. DOWNNewFit Patient

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Pre-Surgery Diet Practice TipsBefore surgery!

▶ Stop using sugar. Use sugar substitutes such as Sweet and Low, Equal or Splenda.

▶ Choose low-fat foods and avoid fried foods.

▶ Stop drinking sugar-sweetened beverages such as regular soda, sweet tea, and sweetened Kool-Aid.

▶ Start weaning off of caffeine and carbonated beverages.

▶ Start cutting back on fast food and eating out. Begin making healthy meal choices when

eating out and at home.

▶ Eat three meals a day. Do not skip breakfast.

▶ Start decreasing portion sizes —buy a food scale and pre-measure portions.

▶ Eat more fruits and vegetables.

▶ Practice drinking water and other calorie-free fluids between meals and not with meals.

▶ Drink 64 ounces of water a day.

▶ Practice sipping liquids. No straws.

▶ Avoid alcohol.

▶ Review the information on the pre- & post-op diet in the Nutritional Guideline packet.

▶ Practice chewing foods thoroughly 20 to 40 times or to a paste consistency.

▶ Purchase your protein drinks or supplements before surgery.

▶ Purchase your vitamin and mineral supplements before surgery.

▶ Begin planning a schedule for mealtime, fluids, vitamin, and minerals.

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Bariatric Surgery ComparisonSurgical Snapshot:

GASTRIC BAND GASTRIC SLEEVE GASTRIC BYPASS

Surgical Difficulty Easiest Easy Moderate

Operation Time 1 Hour 1-2 Hours 2-3 Hours

Operative Risk Safest Safe Moderate

Performed* Laparoscopically Robotic/Laparoscopic Robotic/Laparoscopic

Hospital Stay 0-1 Days 1-2 Days 2 Days

Days to Return to Work** 5-7 Days 7-10 Days 7-10 Days

Initial Weight Loss 1-2 pounds/week 2-4 pounds/week 5+ pounds/week

Total Weight Loss 50% 60-70% 70-80%

Effectiveness High Higher Highest

Maintenance Moderate Lowest Low

* Refers to the method most-commonly used by NewFit for a particular procedure. We perform virtually all gastric bypass and gastric sleeve procedures robotically, depending on individual patient variables and additional criteria.

** Based on average return to work with lifting restrictions or light duty for six weeks after surgery.

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Quality of life improved in95% of patients

Mortality 89% reduction in5-year mortality

Co-Morbidity Reduction After Bariatric Surgery

Migraines57% resolved

Depression55% resolved

Obstructivesleep apnea74-98% resolved

Asthma82% improvedor resolved

Cardiovascular disease82% risk reduction

Hypertension52-92% resolved

GERD72-98% resolved

Stress urinaryincontinence44-88% resolved

Degenerativejoint disease41-76% resolved

Pseudotumorcerebri

96% resolved

Non-alcoholic fattyliver disease

90% resolved steatosis37% resolution of

inflammation20% resolution

of fibrosis

Dyslipdemiahypercholesterolemia

63% resolved

Metabolicsyndrome

80% resolved

Type IIdiabetes mellitus

83% resolved

Venous stasis disease95% resolved

Gout72% resolved

Polycystic ovarian syndrome

79% resolution of hirsutiam100% resolution of mental dysfunction

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BMI vs Mortality

Rel

ativ

e M

ort

alit

y R

ate

BMI (kg/m2)

Low Risk

Medium Risk

High Risk

0

50

100

150

200

250

300

350

16 19 22 25 28 31 34 37 40 45

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Long-Term Survival

0

1

2

3

4

5

6

7

8

0.68%

6.17%

No Surgery

% M

ort

alit

y

Bariatric Surgery

Risk of death decreases

89% reduction in risk of death over 5 years for those

who pursued surgery.

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Notes

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WT B M I4’8” 4’9” 4’10” 4’11” 5’0” 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’0” 6’1” 6’2” 6’3” 6’4” 6’5” 6’6”

200 45 43 42 41 39 38 37 36 34 33 32 31 30 30 29 28 27 26 26 25 24 24 23205 46 44 43 42 40 39 38 36 35 34 33 32 31 30 29 29 28 27 26 26 25 24 24210 47 46 44 43 41 40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 26 25 24215 48 47 45 44 42 41 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26 26 25220 49 48 46 45 43 42 40 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26 25225 51 49 47 46 44 43 41 40 39 38 36 35 34 33 32 31 31 30 29 28 27 27 26230 52 50 48 47 45 44 42 41 40 38 37 36 35 34 33 32 31 30 30 29 28 27 27235 53 51 49 48 46 45 43 42 40 39 38 37 36 35 34 33 32 31 30 29 29 28 27240 54 52 50 49 47 45 44 43 41 40 39 38 37 36 35 34 33 32 31 30 29 29 28245 55 53 51 50 48 46 45 44 42 41 40 38 37 36 35 34 33 32 32 31 30 29 28250 56 54 52 51 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 31 31 30 29255 57 55 53 52 50 48 47 45 44 43 41 40 39 38 37 36 35 34 33 32 31 30 30260 58 56 54 53 51 49 48 46 45 43 42 41 40 39 37 36 35 34 33 33 32 31 30265 60 58 56 54 52 50 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 32 31270 61 59 57 55 53 51 50 48 46 45 44 42 41 40 39 38 37 36 35 34 33 32 31275 62 60 58 56 54 52 50 49 47 46 45 43 42 41 40 38 37 36 35 34 34 33 32280 63 61 59 57 55 53 51 50 48 47 45 44 43 41 40 39 38 37 36 35 34 33 32285 64 62 60 58 56 54 52 51 49 48 46 45 43 42 41 40 39 38 37 36 35 34 33290 65 63 61 59 57 55 53 52 50 48 47 46 44 43 42 41 39 38 37 36 35 34 34295 66 64 62 60 58 56 54 52 51 49 48 46 45 44 42 41 40 39 38 37 36 35 34300 67 65 63 61 59 57 55 53 52 50 49 47 46 44 43 42 41 39 39 38 37 36 35305 69 66 64 62 60 58 56 54 52 51 49 48 47 45 44 43 41 40 39 38 37 36 35310 70 67 65 63 61 59 57 55 53 52 50 49 47 46 45 43 42 41 40 39 38 37 36315 71 68 66 64 62 60 58 56 54 53 51 49 48 47 45 44 43 42 41 39 38 37 37320 72 69 67 65 63 61 59 57 55 53 52 50 49 47 46 45 44 42 41 40 39 38 37325 73 71 68 66 64 62 60 58 56 54 53 51 50 48 47 45 44 43 42 41 40 39 38330 74 72 69 67 65 63 61 59 57 55 53 52 50 49 47 46 45 44 42 41 40 39 38335 75 73 70 68 66 63 61 60 58 56 54 53 51 50 48 47 46 44 43 42 41 40 39340 76 74 71 69 67 64 62 60 59 57 55 53 52 50 49 48 46 45 44 43 41 40 39345 78 75 72 70 68 65 63 61 59 58 56 54 53 51 50 48 47 46 44 43 42 41 40350 79 76 72 71 69 66 64 62 60 58 57 55 53 52 50 49 48 46 45 44 43 42 41355 80 77 74 72 70 67 65 63 61 59 57 56 54 53 51 50 48 47 46 44 43 42 41360 81 78 75 73 71 68 66 64 62 60 58 57 55 53 52 50 49 48 46 45 44 43 42365 82 79 76 74 71 69 67 65 63 61 59 57 56 54 53 51 50 48 47 46 45 43 42370 83 80 78 75 72 70 68 66 64 62 60 58 56 55 53 52 50 49 48 46 45 44 43375 84 81 79 76 73 71 69 67 65 63 61 59 57 56 54 52 51 50 48 47 46 45 43380 85 82 80 77 74 72 70 67 65 63 62 60 58 56 55 53 52 50 49 48 46 45 44385 87 84 81 78 75 73 71 68 66 64 62 60 59 57 55 54 52 51 50 49 47 46 45390 88 85 82 79 76 74 72 69 67 65 63 61 59 58 56 55 53 52 50 49 48 46 45395 89 86 83 80 77 75 72 70 68 66 64 62 60 58 57 55 54 52 51 50 48 47 46400 90 87 84 81 78 76 73 71 69 67 65 63 61 59 58 56 54 53 51 50 49 48 46405 91 88 85 82 79 77 74 72 70 68 66 64 62 60 58 57 55 54 52 51 49 48 47410 92 89 86 83 80 78 75 73 71 68 66 64 63 61 59 57 56 54 53 51 50 49 48415 93 90 87 84 81 79 76 74 71 69 67 67 63 61 60 58 56 55 53 52 51 49 48420 94 91 88 85 82 80 77 75 72 70 68 66 64 62 60 59 57 56 54 53 51 50 49425 96 92 89 86 83 81 78 75 73 71 69 67 65 63 61 59 58 56 55 53 52 51 49430 97 93 90 87 84 81 79 76 74 72 70 68 66 64 62 60 58 57 55 54 52 51 50435 98 94 91 88 85 82 80 77 75 73 70 68 66 64 63 61 59 58 56 55 53 52 50440 99 95 92 89 86 83 81 78 76 73 71 69 67 65 63 62 60 58 57 55 54 52 51445 100 97 93 90 87 84 82 79 77 74 72 70 68 66 64 62 61 59 57 56 54 53 52450 101 98 94 92 88 85 83 80 77 75 73 71 69 67 65 63 61 60 58 56 55 54 52455 102 99 95 92 89 86 83 81 78 76 74 71 69 67 65 64 62 60 59 57 56 54 53460 103 100 96 93 90 87 84 82 79 77 74 72 70 68 66 64 63 61 59 58 56 55 53465 105 101 97 94 91 88 85 83 80 78 75 73 71 69 67 65 63 62 60 58 57 55 54470 106 102 98 95 92 89 86 83 81 78 76 74 72 70 68 66 64 62 61 59 57 56 54475 107 103 100 96 93 90 87 84 82 79 77 75 72 70 68 66 65 63 61 60 58 56 55480 108 104 101 97 94 91 88 85 83 80 78 75 73 71 69 67 65 64 62 60 59 57 56485 109 105 102 98 95 92 89 86 83 81 78 76 74 72 70 68 66 64 62 61 59 58 56490 110 106 103 99 96 93 90 87 84 82 79 77 75 73 71 69 67 65 63 61 60 58 57495 111 107 104 100 97 94 91 88 85 83 80 78 75 73 71 69 67 65 64 62 60 59 59

What is Your BMI?

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Patient Information Patient Name ______________________________________________________________________________________________ M F

Date of Birth___________________________________________ Social Security Number__________________________________________

Address _______________________________________________________________________________________________________________

City_______________________________________________________________State_____________ Zip _______________________________

Phone ______________________________Cell __________________________ Email Address_______________________________________

Height___________________ Weight ___________________ BMI _____________________

Check the procedure most interested in: Gastric Band Gastric Sleeve Gastric Bypass Revision/Different (I’ve had Bariatric Surgery)

Please let us know about your interest in proceeding (check one below): I’m ready now in 1-2 months in 3-6 months >6 months Unsure Never

Please check all that apply to you: Morbid Obesity Asthma High Cholesterol

Obstructive Sleep Apnea Depression Osteoarthritis

Type II Diabetes GERD/Heartburn Hypertension/High BP

Pseudo Tumor Cerebri Urinary Stress Incontinence Swelling of the Legs (Edema)

Primary InsuranceInsurance __________________________________________________________ Policy #/Subscriber ID _______________________________

Group ___________________________Phone _____________________________ Policy Holder’s DOB _______________________________

Policy Holder’s Name ______________________________________________Relationship to Patient _______________________________

Employer’s Name_______________________________________________________________________________________________________

Secondary InsuranceInsurance __________________________________________________________ Policy #/Subscriber ID _______________________________

Group ___________________________Phone _____________________________ Policy Holder’s DOB _______________________________

Policy Holder’s Name ______________________________________________Relationship to Patient _______________________________

Employer’s Name_______________________________________________________________________________________________________

Primary Care PhysicianPrimary Care Physician’s Name_______________________________________________________Phone______________________________

Address _______________________________________________________________________________________________________________

City_______________________________________________________________State_____________ Zip _______________________________

Insurance VerificationI, _____________________________________________________________________ , authorize the verification of insurance benefits to

Dr. Nathan Allison Dr. Kenneth Tieu

Signed____________________________________________________________ Date _______________________

Insurance Benefit WorksheetSeminar Date______________________________________

(Please fill out as completely as possible. Thank you!)

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Patient Health History Form(page 1 of 2)

Patient Name___________________________________________________________________________

Date of Birth___________________________________________ Date____________________________

Pharmacy/Address/Phone #______________________________________________________________________________________________

Active Medical Problems:

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

Significant Past Medical Problems:

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

Surgery (List all surgeries you’ve had—procedure & date):_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Family History: Circle & state relation to you: Social History:Breast Cancer ________________________Hypertension _________________________Lung Cancer _________________________Diabetes _____________________________Colon Cancer _________________________Heart Disease ________________________

Thyroid Cancer _______________________Stroke _______________________________Lymphoma/Leukemia __________________Heart Prostate Cancer _________________Kidney Disease ________________________Heart Attack __________________________

Do you smoke? Y N If yes, how much? How long? _____Do you drink alcohol? Y NMore than 3 beers or 2 drinks/day? _____Have you ever used drugs? Y NIn the past? Y N Currently? Y N

Women Only: Have you had a hysterectomy? Y NHave your ovaries been removed? Y N If yes, RT / LT / BothHave you had a tubal ligation (tubes tied)? Y N

Previous Breast Biopsy? ____________________Date & Location of last mammogram:

__________________________________________________________

Medications: Are you currently taking any medications? Y N Coumadin/Warfarin Y N Plavix Y N Aspirin Y NPain Medications ____________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies: Please CirclePenicillin / Sulfa / MycinsCipro / Levaquin / Other ___________________________________Latex X-Ray DyeTetanus Toxoid / FoodsMorphine / Codeine / DemerolPercocet / Lortab / OxycodoneOther ____________________________________________________

Be sure to include any vitamins and over-the-counter medicines.Medication Name:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________

Strength / Mg:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Frequency / Dose:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Attach a separate page if needed, list all medications you take.

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Patient Health History Form(page 2 of 2)

Patient Name_________________________________________________________________

Date of Birth______________________________________ Date_______________________

System Review (Please circle any of the following you are currently experiencing or have in the past):

Constitutional: FeverChillsMalaiseNight SweatsWeight Gain

Eyes:Blurred VisionDouble VisionCorrective GlassesSurgeryHoarsenessNose Bleeds

Ears / Nose / Throat:Hearing LossSore ThroatDifficulty SwallowingHoarsenessNose Bleeds

Respiratory / Lungs:AsthmaCOPDEmphysemaSleep ApneaChronic or Frequent CoughCPAP MachineShortness of Breath with Mild ExertionWheezingCoughing up BloodLung MassTuberculosisPulmonologist’s Name: _____________________

Cardiovascular / Heart:Heart AttackChest PainRheumatic FeverCHFIrregular Heart BeatHigh Blood PressurePacemakerAngioplastyCardiac StentsDefibrilatorCardiac CathDate: __________________Name of Cardiologist: ______________________

Genitourinary / Kidney / Bladder:Pain with UrinatingKidney StonesUrinary Frequency (# of times / night ___)Prostate DiseaseCancerNephrologist’s Name: ______________________

Hematologic / Lymphatic:AnemiaLeukemiaLymphomaLymph Node EnlargementSickle CellLymph Node BiopsyBleeding GumsHematologist’s Name: ______________________

Psychiatric:DepressionAnxietyAlcohol AbuseDrug AbuseMood swings

Gastrointestinal:Abdominal PainNauseaVomitingAcid RefluxConstipationDiarrheaColitisUlcersGallstonesPancreatitisJaundiceDiverticulitisDiverticulosisColon PolypsColon CancerVomiting BloodBloody StoolsBlack StoolsHemorrhoidsLast Colonoscopy: _________________________Last EGD: _________________________________

Endocrine:DiabetesThyroid DiseaseParathyroid DiseaseAdrenal DiseaseHeat / Cold IntoleranceEndocrinologist’s Name: ____________________

Neurologic:Recurrent HeadachesMigrainesEpilepsyTiaStrokeSyncopeMemory LossNeurologist’s Name: ________________________

Musculoskeletal:FractureBack PainDisc DiseaseJoint PainSurgery: ______________________

Integumentary / Skin:Rashes / Skin Cancer / HerpesMelanoma / Burns

Breast:PainMassNipple Discharge

Vascular:Venous Stasis UlcersBypassAAAVaricose VeinsVascular StentsLeg Pain With WalkingSleeping

Other Conditions Not Listed:

________________________________________________________________________________________________________________________________________________________________

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Weight Loss Attempts Patient Name___________________________________________________________________________

Date of Birth___________________________________________ Date____________________________

PROGRAM YEAR # OF MONTHS WEIGHT LOSS

Acupuncture, Hypnosis, Jaw Wire

Atkins

Behavior Modification

High Protein/Low Card

Injections: HCG/B-12

Jenny Craig

Medifast

Nutrisystem

Opti Source

Other Diet Centers/Programs

Overeaters Anonymous

Fen-Phen/Other Medications

Physician or Dietician Directed & Supervised

Previous Weight Loss Surgery

Self-Monitored Diet & Exercise

Slim-Fast

Weight Watchers

Other: ____________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

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Seminar QuestionnaireImportant Information!Seminar Date: ____________________

Facility:___________________________________________________________

We are excited that you attended. We hope you enjoyed the presentations and found them educational. In order to serve you better, would you please take a moment and answer the following questions.

Satisfaction Scale: 1 = Not Satisfied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 = Very Satisfied

1. Overall Educational Value: 1 2 3 4 5

Comments: ______________________________________________________________________________________________________

2. Financial Information: 1 2 3 4 5

Comments: ______________________________________________________________________________________________________

3. What is the most important factor in your decision to pursue weight loss surgery? (Please check one.)

Surgeon Procedure Facility Affordability Other: ________________________________________________

4. How likely are you to move forward with surgery? Very Likely Unlikely

If likely, please check one of the options below.

Within 1-2 months Within 3-6 months > 6 months

5. How did you find out about this seminar? (Please check all that apply.)

Billboard Newspaper Magazine Email Physician Name: __________________________________________

Internet TV Radio Friend or Relative Other: ____________________________________________________

6. Have you attended other weight loss program seminars in the area? Y N

If yes, where: ____________________________________________________________________________________________________

7. Would you recommend this seminar to a family member or friend?: Y N

If not, why: ______________________________________________________________________________________________________

ADDITIONAL RECOMMENDATIONS/COMMENTS: ____________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

8. Do you have any additional questions we did not cover?

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Thank you again for attending and providing us with your input.

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Documents

‘Getting Started’ - Brevard Florida Health Insurance · PDF fileMIND DIET EERCISE BEYND ‘Getting Started’ This packet contains the following important information to assist