CALL:1-877-234-4668
 
Take this assessment to see how much weight you could lose on one of our personalized plans.
 
Gender: male female
 
Height: ft in
 
Age: yr
 
Weight: lbs
 
E-mail:
 
send me weight loss tips and more!
 
Privacy Policy
Results based on your current Body Mass Index (BMI)
and Basal Metalogic Rate (BMR)
 
Real weight loss begins with you. If you tried everything and are serious about weight loss,
taking control and regaining your health then
read on.
 
 
 
Dear Clients

Please complete the following Nu Beginnings admission questionnaire as best as possible. Spending the time to complete our easy questionnaire will make your office visit nearly hassle free.

The Nu Beginnings program may be covered by medical insurance, if certain qualifications are met. When you have completed the form, please click on the submit button below and an intake coordinator will contact you within one business day to arrange your free initial consultation. We look forward to helping you with your journey!
 
PATIENT INFORMATION
Name:
Email Address:
Phone Number:
Address Line 1:
Address Line 2:
City:
State:
Zip:
 
Sex Female Male
Age
Height inches
Current Weight lbs.
Birth Date Social Security #:
Driver's License #
Race
Caucasian Black Asian Hispanic Other
Marital Status
Single Married Separated Divorced Widowed
How many children do you have?         Ages
Lifetime maximum weight lbs.
Age at which you first became 75 lbs. or more overweight
Age at which you first became 75 lbs. or more overweight
Less than normal Overweight (75 lbs or less) Very overweight (more than 75 lbs)
How do you believe that others perceive your body weight?
Less than normal Overweight (75 lbs or less) Very overweight (more than 75 lbs)
Number of weight loss methods tried previously (please provide a number even if you are unsure of the total)
How many times have you lost 20 or more pounds? (answer with a number even if it is only a guess)
Main reason for wanting treatment for weight loss?
INSURANCE INFORMATION
 
Required: Please give us all pertinent information regarding your insurance coverage. If you have coverage by more than one carrier, supply information of all.
No coverage Cigna Worker's Comp
Aetna United Other
Blue Cross PHCS  
     
 
Required: In order to submit a claim for payment to us for services covered under you policy, we must have your authorization to release medical information to your insurance carrier.
HMO PPO EPO
POS CASH  
     
 
Medicare and Medicaid: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. I request that payment under the medical insurance program be made either to me or to Texas Spine Institute or Synergy Health Group on any bills for services furnished me by Nu Beginnings during the next 12 month period.

All Other Insurance: I hereby authorize Nu Beginnings to submit a claim to my insurance carrier or its intermediaries for all covered services rendered by the physician(s) and authorize and direct my insurance carrier or its intermediaries regarding services rendered.

Payment Default: In the event of payment default, I agree to be responsible for any and all collection fees.
 
I have read and agree to the above statement.
 
 
Company Name PRIMARY SECONDARY
Company Address
Company Phone
ex. xxx-xxx-xxxx
Insured's name
Insured's policy Number
Insured's Group Number
 
EMPLOYMENT
Are you employed? Yes No
Employer name
Employer phone
Employer Address
Occupation
FAMILY PHYSICIAN
Physician Name
Physician Address
(max 200 chars)
Physician Phone ex. xxx-xxx-xxxx
FAMILY HISTORY
   
Counting yourself, your full brothers and sisters, and your parents, how many people are in your immediate family?
   
How many people in your immediate family (yourself included) were at one time or another 75 lbs. or more overweight?
   
DOES ANYONE IN YOUR FAMILY HAVE...
...Diabetes? Yes  Relation:
...High blood pressure? Yes  Relation:
...Heart disease? Yes  Relation:
...Stroke? Yes  Relation:
OPERATIONS
List all previous
operations/ anesthetics		 OPERATION TYPE OF ANESTHESIA PROBLEMS (if any)
ILLNESSES
List all serious illnesses
MEDICATIONS
     
What medications are you taking? [Do not forget such things as aspirin, cortisone, blood pressure medication, thyroid, tranquilizers, hormones, birth control pills, laxatives, vitamins, etc.] MEDICINE FREQUENCY
Have you ever taken...    
Phen-fen? Yes  If yes, then for how long?
Phentermine? Yes  If yes, then for how long?
Xenical? Yes  If yes, then for how long?
Meridia? Yes  If yes, then for how long?
ALLERGIES
Are you allergic to any medications? (If yes, list medications) Yes No
MEDICATION REACTION
Do you have food allergies? Yes No
Check if you have any of these Egg/Soy bean allergy Hay fever Childhood Eczema
EATING HABITS
Do you eat breakfast? 3 or more days a week 1 or 2 days a week
Do you snack at night? 3 or more days a week 1 or 2 days a week
Do you snack during the day? 3 or more days a week 1 or 2 days a week
Do you drink soda or other very sugary liquids? 3 or more days a week 1 or 2 days a week
Do you eat desserts? 3 or more days a week 1 or 2 days a week
Do you eat fried foods? 3 or more days a week 1 or 2 days a week
Do you binge eat? (Bingeing means that you eat a lot more than you feel you should eat.) 3 or more days a week 1 or 2 days a week
How large are your meals compared to normal weight people eating the same meal? Smaller Larger
SMOKING AND DRINKING
How many cigarettes (or packs) do you smoke a day? cigarettes     packs
Do you drink alcohol? Never Occasionally
(once a week or so) 		Daily
Have you ever been in an alcohol rehabilitation program? Yes No
SLEEPING
How often do you have restless sleep or frequent awakening? 2 or more days a week Fewer than 2 days a week
How often do you have night sweats? 2 or more days a week Fewer than 2 days a week
How often do you snore? 2 or more days a week Fewer than 2 days a week
How often do you have daytime sleepiness? 2 or more days a week Fewer than 2 days a week
How often do you have morning headaches? 2 or more days a week Fewer than 2 days a week
In the past year, has anyone told you that you held your breath for a long time while asleep? Yes No
Do you wake at night with a snort or gasp? Yes No
RESPIRATORY
Spitting of blood? Never Now
Have you had bronchitis? Yes No
Have you had emphysema? Yes No
Have you been diagnosed or treated for asthma? Yes No
 If yes, list medications used:
Year of last chest x-ray?  Normal? Yes No
CARDIOVASCULAR
Chest pain or angina pectoris? Never Now
Heart murmur? Never Now
Have you ever had palpitations/ arrhythmia Yes No
Have you had a heart attack? Yes No
Have you been diagnosed or treated for High Blood Pressure? Yes No
 If yes, list medications used:
Have you had varicose veins? Never Now
Have you had blood clots or phlebitis
(inflammation in the leg veins)?		 Yes No
Year of last EKG? Yes No
Do you have shortness of breath after climbing
one flight of stairs?		 Never Now
How many blocks can you walk without having to
stop for breath?
How many days a week do you exercise on average?
GASTROINTESTINAL
Tarry black stool or blood in bowel movements? Never Now
Crampy abdominal pain? Never Now
Chronic constipation? Never Now
Frequent diarrhea? Never Now
Change in bowel habits? Never Now
Hemorrhoids or piles? Never Now
Have you been diagnosed as having stomach or intestinal ulcers or other disorders of the gastrointestinal system? Never Now
Have you had hepatitis or liver problems? Never Now
Ever vomit blood? Never Now
Do you have heartburn? Never Now
URINARY
Have you had kidney problems? Never Now
Burning or painful urination? Never Now
Frequent urination? Never Now
Feeling you must go immediately? Never Now
Do you lose small amounts or urine with coughing or straining? Never Now
Blood in urine? Never Now
Kidney stones? Never Now
GYNECOLOGICAL
Have you had gynecological (female) problems? Never Now
Are you or might you be pregnant? Never Now
Do you experience menstrual difficulties? None Heavy periods Painful periods
MUSCULOSKELETAL
Arthritis, swollen or painful joints? Never Now
Pain in calves or buttocks when walking,
relieved by rest?		 Never Now
How often do you have swelling of ankles? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - back? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - hip? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - knee? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - ankle? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - foot? 2 or more days a week Fewer than 2 days a week
SKIN
Frequent infections? Never Now
Unusual moles or lumps? Never Now
Describe unusual moles or lumps:
   
HEAD
Eye disease or injury? < Never Now
Double Vision? Never Now
Headaches? Never Now
Rarely Frequently
Minor Severe
Epilepsy or seizures? Never Now
Brain disease or Strokes? Never Now
MENTAL HEALTH
Are you satisfied with your social life? Yes No
Were you ever severely abused?(check all that apply) Emotionally Sexually
Are you satisfied with your sex life? Yes No
How would you rate your self esteem level? Low High
How would you rate your energy level? Low High
Do you have trouble sleeping? Never Now
Are you usually tired? Never Now
Are you often depressed? Never Now
Are you often anxious or nervous? Never Now
Do you ever wish you were dead and away
from it all?		 Never Now
Have you ever seen a psychiatrist? Yes No
Name
Address
Phone
Have you ever been hospitalized for psychiatric reasons? Yes No
HEMATOLOGICAL
Anemia? Never Now
Excessive bleeding or abnormal bruising? Never Now
Have you ever received a blood transfusion? Never Now If yes, in what year?
ENDOCRINE
Hormone therapy?   Now
Have you been diagnosed or treated for Diabetes? Yes No
  If yes, list medications used:
Have you been told that you have Gallstones? Yes No
Thyroid Problem? Never Now
METHODS OF WEIGHT CONTROL USED IN THE PAST
Doctor Supervised Programs TYPE WHEN PROGRAM
Rader Institute
Lindora
Fasting
B-6
Amphetamines
Opti-Fast
Schick Center
Medifast
HCG Shots
B-12
Other weight loss pills
Other
Traditional Weight Loss Programs TYPE WHEN PROGRAM
Jenny Craig
Over Eater’s Anonymous
Weight Watchers
Nutri System
"Fat Farms"
Exercise program
Other
Non-traditional Weight Loss Programs TYPE WHEN PROGRAM
Gastric Bubble
Acupuncture
Jaw wiring
Hypnosis
Other
Self Diets TYPE WHEN PROGRAM
Slim Fast
Dieter’s tea
Accutrim
Dexatrim
Cal Ban 3000
Fasting
Other
Popular Diet Programs TYPE WHEN PROGRAM
Scarsdale Diet
Herbal Life
Bahamian Diet
Beverly Hills Diet
Pritikin Diet
Cambridge Diet
R. Simmons’ Deal-A-Meal
Other
Nutritional Programs TYPE WHEN PROGRAM
In-Hospital
Hospital/Clinic Name:
Out-Patient
Hospital/Clinic Name:
Previous Weight Loss Surgery Procedures TYPE WHEN HOSPITAL/CLINIC NAME
Gastric Bypass
Adjustable LAP-BAND® Surgery
Vertical Band Gastroplasty
Other
WHO CAN WE THANK FOR THIS REFERRAL?
I heard about Nu Beginnings from
Name & Address (if you selected "Physician" or "Current Patient") Name:
Address:
Final Comments (max 1000 characters)
 
If you have filled out all of the answers to the best of your knowledge click the Submit button below.