DOCSLIB.ORG

Does the Client Have Any of the Following Conditions?

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Does the Client Have Any of the Following Conditions? t for each dieter . This will be completed by the consultan otocol and Advisor y Notes. Please use this form with the Medical Pr 1. Contact Details 2. Personal Details Name Age DOBGender Address Occupation Typical weekly activity/exercise □Sedentary □Moderate □Very active Email Previous dieter? □Yes □No Phone Height Waist Weight BMI 3. Medical Information Does the client have any of the following conditions? Contraindicated Step 1B minimum ○ Alcoholic/substance misuser within one year of recovery ○ Spinal conditions (Such as Sciatica, spondylitisis, scoliosis) ○ Anti-obesity medication treated with medication ○ Serious illness, trauma or surgery (within the last three ○ Neuro/muscular conditions (such as MS, Fibromyalgia) months) ○ Anaemia ○ Antibiotic medication ○ Serious mental health episode; such as schizophrenia, ○ Constipation ○ Crohn’s disease, ulcerative colitis, IBS delusional disorder, psychotic episode, bi-polar disorder ○ Diverticular disease ○ Gall stones (within the last six months) ○ Pain relief (moderate to strong) ○ Vertigo ○ Current active anorexia, bulimia, or currently undergoing treatment for any eating disorder Step 1B minimum & Monitoring letter Kidney disease/failure Liver disease/failure ○ Heart failure/attack, arrhythmia, valve disease requiring ○ ○ treatment (within the last three months) ○ Mental health disorders (stable) ○ MAOI medication ○ Angina/Arrythmia (stable) ○ Gout ○ Stroke or TIA (within the last three months) ○ Anti-coagulant medication (such as warfarin) Pregnant, breastfeeding or given birth in the last three ○ Any step & monitoring letter months ○ Cholesterol medication Requires MEF ○ Diabetes Type 2 (controlled by diet or metformin and/or ○ Diabetes Type 1 sitagliptin) ○ Diabetes Type 2 (controlled by more than Metformin) ○ Diuretics (Water tablets) ○ Gastric surgical procedures (within one year) ○ Hypertension (high blood pressure) ○ Thyroid medication Or ○ None Apply Step 4 minimum & Monitoring letter Any other medical conditions or medications: ○ Fertility medication Step 3 minimum ○ Smoking cessation medication (such as Champix) ○ Stomach ulcer ○ Kidney stones Any allergies or intolerances: Step 1B minimum ○ Cancer in remission ○ Epilepsy If you put a condition in any of these boxes and are ○ Porphyria ○ Diabetes Insipidus unsure of the advice to give your dieter, please submit an ○ Psoriasis ○ Rheumatoid arthritis treated with medication MEF in the usual process. 4. Client Declaration 5. Consultant Please confirm the following and sign the interest which forms the legitimate basis for I will abide by the Code of declaration: processing. 1. The information given is correct and I have been 5. I am aware that it is my responsibility as a Conduct (CRL202) advised to consult my GP before starting any client to have regular medical reviews with weight loss programme. my GP to assess any medication adjustments. Name 2. I understand the importance of following the 6. I have been supplied with the relevant The 1:1 ID No selected Step according to directions given by booklet and The 1:1 privacy notice by my my Consultant and additional literature supplied Consultant and I have read and understood Phone by The 1:1. these prior to completing this form. 3. If my health status/medication changes while Client agreement OM onitering letter sent using any The 1:1 Step, I agree to notify my O I agree with the above statements Consultant. O I consent to my Consultant contacting me at OM EF sent 4. I understand that there is a legitimate interest in any point regarding my weight loss journey, ON /A The 1:1 and my Consultant holding the data on promotions and any business opportunities. If I the Personal Record Form in conjunction with wish to withdraw my consent at any stage I can my use of the Programme. I understand it may do so by sending an email to my Consultant. Signed be necessary for you to provide data to medical Date professionals and vice versa in relation to me Signed______________Date_________ starting the Programme and that this is a vital Netturul Resources Sdn Bhd 201001020155 (903910-D) (AJL 931857).
Load more

Recommended publications
  • Criteria and Application for Women
    Criteria and Application for Women Retu Rn completed fo Rm via fax o R email to LIVESTRONG Foundation attn LIVESTRONG Fertility fax 512.309.5515 email [email protected] Made possible by participating reproductive endocrinologists and EMD Serono, Inc. © LIVESTRONG, a registered trademark of the LIVESTRONG Foundation. The LIVESTRONG Foundation is a 501(c)(3) under federal tax guidelines. The Foundation and its partners reserve the right to review patient profiles and to grant requests based on patient need. Goal The goal of LIVESTRONG Fertility is to increase access to fertility preservation services and treatments for qualified women who are diagnosed with cancer during their reproductive years. We are proud to offer assistance to qualified female applicants by providing access to fertility medications donated by EMD Serono, Inc. and discounted services from reproductive endocrinologists across the country. oveRview LIVESTRONG Fertility does not grant direct financial contributions to individuals. Instead, the LIVESTRONG Foundation has partnered with key organizations to increase access to procedures and treatments intended to preserve the possibility of fertility for qualified cancer patients whose medical treatments present the risk of infertility and who meet the criteria set forth below. For a list of participating facilities, please call 855.220.7777. what is included LIVESTRONG Fertility helps reduce the cost of embryo freezing and egg freezing procedures. A limited quantity of certain medications prescribed by a reproductive endocrinologist to assist in the development of multiple follicles through ovarian stimulation will be provided through a donation from EMD Serono, Inc. to qualified applicants (see eligibility criteria). Additionally, partnering local reproductive endocrinologists will offer embryo and egg freezing services at a significantly discounted rate.
    [Show full text]
  • The Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Study
    Supplementary Online Content Inge TH, Zeller MH, Jenkins TM, et al; Teen-LABS Consortium. Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Study. JAMA Pediatr. Published online November 4, 2013. doi:10.1001/jamapediatrics.2013.4296. eAppendix. Research Plan and eCRF Data Collection Forms eTable 1. Central Laboratory Measures by Reference Category eTable 2. Laboratory Measures Summarized eTable 3. Reasons for Readmission Within 30 Days of Operation This supplementary material has been provided by the authors to give readers additional information about their work. © 2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 eAppendix Research Plan A. Design Summary: The study used a prospective, observational cohort design in which the majority of the data are collected at the same time that routine clinical care of bariatric patients is occurring. Teen-LABS is an approved ancillary study of the LABS consortium, with the research methodology and instruments of the LABS-2 study for collection of longer term outcomes adapted for use in adolescents, including clinical assessments, detailed interviews, questionnaires, and laboratory tests at baseline, 30 days postoperatively, and at six months and annually following surgery. Adolescents were recruited prospectively from five clinical sites. Detailed data about the surgical procedure and peri- and postoperative care was collected by the investigators. Adjudication of pre-specified clinical events was performed by an independent committee in order to determine the relatedness of the events to the bariatric procedure. Biospecimens (serum, plasma, DNA, urine) were obtained to address hypotheses relevant to this study and to provide a resource for future biological studies.
    [Show full text]
  • Safety and Quality Aspects of IVF - Neonatal and Maternal Outcomes Following Advanced Techniques
    Safety and quality aspects of IVF - neonatal and maternal outcomes following advanced techniques Erica Ginström Ernstad Department of Obstetrics and Gynecology Institute of Clinical Science Sahlgrenska Academy University of Gothenburg Gothenburg, Sweden Gothenburg 2020 Cover illustration: Tubies by Stina Rosén Safety and quality aspects of IVF – neonatal and maternal outcomes following advanced techniques © Erica Ginström Ernstad 2020 [email protected] ISBN 978-91-7833-782-8 (PRINT) ISBN 978-91-7833-783-5 (PDF) http://hdl.handle.net/2077/63272 Printed in Borås, Sweden 2020 Printed by Stema Specialtryck AB "If we knew what it was we were doing, it would not be called research, would it?" Albert Einstein Safety and quality aspects of IVF - neonatal and maternal outcomes following advanced techniques Erica Ginström Ernstad Department of Obstetrics and Gynecology, Institute of Clinical Science Sahlgrenska Academy, University of Gothenburg Gothenburg, Sweden ABSTRACT Background: Singletons born following assisted reproductive technology (ART) have adverse neonatal outcome compared to singletons born following spontaneous conception (SC). Moreover, the women undergoing ART are at an increased risk of hypertensive disorders in pregnancy (HDP) and placental complications. Aim: To study the neonatal and maternal outcomes following the introduction of advanced techniques in ART. Material and methods: All papers were population-based register studies in Sweden with cross linkage of the national ART registers and national health data registers. In paper III also Danish register data were included. Paper I Singletons born after blastocyst transfer (n=4819), singletons born after cleavage stage transfer (n=25,747) and singletons born after SC (n=1,196,394) were included.
    [Show full text]
  • Patient Orientation Guide
    Patient Orientation Guide Mar 2015 Table of Contents Welcome to PCRM ...................................................................................................................... 3 Our Mission ................................................................................................................................. 3 Our Vision .................................................................................................................................... 3 Clinic Hours .................................................................................................................................. 3 Treatment Monitoring Guidelines .............................................................................................. 4 Treatment Reminders ................................................................................................................. 4 Infertility ...................................................................................................................................... 5 Treatment Options ...................................................................................................................... 7 Ovulation Induction ..................................................................................................................... 7 Intrauterine Insemination (IUI) ................................................................................................... 9 In Vitro Fertilization (IVF) .........................................................................................................
    [Show full text]
  • Phd Thesis Ninagran Egeland.Pdf (3.008Mb)
    Discovery and Validation of Biomarkers in Breast Cancer by Nina Gran Egeland Thesis submitted in fulfilment of the requirements for the degree of PHILOSOPHIAE DOCTOR (PhD) Faculty of Science and Technology Department of Chemistry, Bioscience and Environmental Engineering 2020 University of Stavanger NO-4036 Stavanger NORWAY www.uis.no ©2020 Nina Gran Egeland ISBN: 978-82-7644-953-2 ISSN: 1890-1387 PhD: Thesis UiS No. 546 Scientific Environment The present PhD-project was conducted in its entirety at the Department of Pathology, Stavanger University Hospital, Stavanger, Norway. In affiliation with the Department of Chemistry, Bioscience and Environmental Engineering, Faculty of Science and Technology, University of Stavanger, Stavanger, Norway. Supported by generous grants from the Folke Hermansen Foundation, in 2013 and 2019. Acknowledgements Acknowledgements First and foremost, I would like to express my deepest gratitude to my main supervisor Professor Emiel Janssen. Ever since I knocked on your door in search for employment in 2012, you have supported and motivated me throughout this long journey. I admire your vast knowledge and insight in the complex world of breast cancer research and pathology. You are an inspiration to me, I highly respect your professional competence, and I could not have hoped for a better mentor. But most importantly, I will never forget your understanding, kindness and compassion after I fell ill, and how you kindly encouraged me to complete this thesis thereafter. I am forever grateful. The best boss in the world! To my committed co-supervisor Kristin Jonsdottir, who equally appreciate the utmost importance of accuracy in formatting, straight lines, and symmetry in powerpoints and word-documents.
    [Show full text]
  • Download Our Welcome Packet
    Welcome Welcome to Village Fertility Pharmacy. Thank you for choosing our pharmacy to fulfill your medication needs. With more than 30 years in the fertility pharmacy business, we understand that starting a family can be a challenging and emotional journey. Your care is very important to us. We have developed this welcome letter to introduce you to our services. We are here to support you through your medication therapy — any time you need us. Our toll-free phone line, (877) 334-1610, is staffed by dedicated and experienced Patient Care Coordinators, Nurses and Pharmacists from 8:00am-8:00pm ET Monday through Friday, and from 8:30am to 5:00pm on Saturday. We offer on-call clinical support 24 hours a day for your after-hours emergency services and questions. You may also reach us on the same toll-free phone line for questions regarding: • How to fill and/or refill prescription; • The status of an order; • To Request transfer of prescription to or from the pharmacy; • Information about order delays; • Suspected medication issues; • Complaints (including medication, errors or adverse drug events); or, • Emergency preparedness Please visit our website: www.villagepharmacy.com for a complete overview of our service offerings, including helpful injection teaching videos and links to many supportive services. Walk-in service is available at our pharmacy, located at 335 Bear Hill Road, Waltham, MA. We are pleased that you have entrusted Village with your pharmacy care. We will do our very best to support you through your therapy. - Your Village Fertility Pharmacy Care Team Please review the Village Fertility Pharmacy Welcome Kit, including the information listed below on our website www.villagepharmacy.com under Patient Resources.
    [Show full text]
  • The Impact of Biosimilar Competition in Europe Contents
    May 2017 The Impact of Biosimilar Competition in Europe Contents 01 Introduction 02 Definitions 03 Four Observatons by QuintilesIMS 09 The country and therapy areas KPIs 09 Epoetin (EPO) 11 Granulocyte colony-stimulating factor (G-CSF) 13 Human growth hormone (HGH) 15 Anti-tumor necrosis factor (Anti-TNF) 18 Fertility (Follitropin alfa) 20 Insulins 23 Reading guide 27 Appendices 27 EMA list of approved Biosimilars 28 Methodology 29 QuintilesIMS source of volume data 30 QuintilesIMS source of price data The Impact of Biosimilar Competition in Europe Page 2 Introduction This document sets out to describe the effects on price, volume and market share following the arrival and presence of biosimilar competition in the European Economic Area (EEA). The report consists of a set of Key Performance Indicators (KPI’s) to monitor the impact of biosimilars in European markets, using full year 2016 data. This report has been prepared by QuintilesIMS at the request of the European Commission services with initial contributions from EFPIA, Medicines for Europe, and EuropaBio. The European Medicines Agency (EMA) has a central role in setting the rules for biosimilar submissions, approving applications, establishing approved indications and monitoring adverse events, and if necessary issue safety warnings. We have, when appropriate, quoted their information and statements. The Impact of Biosimilar Competition in Europe Page 1 Definitions The report uses some basic terms defined as follows: • Accessible category: products within the same ATC4 code including the following three product categories: • Referenced Medicinal Product: Original product, granted market exclusivity at the start of its life, exclusivity has now expired and the product has been categorised as referenced.
    [Show full text]
  • Munich - Germany 29 June to 2 July 2014 FINAL PROGRAMME 2
    00-ESHRE 2014Couverture+Dos12,5_ESHRE26/05/1409:16Page1 Munich - Germany 29 June to 2 July 2014 FINAL PROGRAMME 2 912235_Final Programme 2014.indd 2 23/05/14 09:34 p3.pdf 1 27/05/14 11:40 CONTENTS Welcome Letter 05 CONTENTS Committees 07 Pre-congress courses 11 Scientific Program: Monday, 30 June 2014 30 Scientific Program: Tuesday, 1 July 2014 62 Scientific Program: Wednesday, 2 July 2014 98 Posters 125 Author Index 215 General Information 239 Agenda Annual General Assembly of Members 243 Social Programme 245 Corporate Members 247 Industry Sponsored Symposia 248 FINAL PROGRAMME I MUNICH, GERMANY - 29 JUNE TO 2 JULY 2014 3 4 912235_Final Programme 2014.indd 4 23/05/14 09:34 WELCOME Dear Friends and Colleagues, On behalf of the Local Organising Committee it gives me a great pleasure to welcome you to the 30th Annual Meeting WELCOME of ESHRE in Munich, Germany from 29 June to 2 July 2014. After Bonn 1985, Hamburg 1995 and Berlin 2004, Munich is the fourth city in Germany to host an ESHRE Annual Meeting. Munich is known throughout the world as a dynamic and economically successful city in the southern part of Germany, with many traditional attractions. The Bavarian capital, set in a beautiful landscape, offers all the advantages you would expect of a leading international congress and exhibition venue in the heart of Europe. Art, culture, recreational activities and sightseeing provide enjoyable possibilities every day. Munich in the summer is a charming and exhilarating place. The venue chosen for this event is the ICM - International Congress Centre Munich - one of the most modern and successful congress centres in the world well equipped to satisfy all the requirements of an event such as our Annual Meeting.
    [Show full text]
  • Fertility Drugs and Multiple Births.Qxd
    AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE 1209 Montgomery Highway • Birmingham, Alabama 35216-2809 • TEL (205) 978-5000 • FAX (205) 978-5005 • E-MAIL [email protected] • URL www.asrm.org PATIENT FACT SHEET Fertility Drugs and the Risk of Multiple Births Infertility treatments make it more likely that you will You may need to stay in bed or even stay in the hospital for become pregnant with twins, triplets, or more. This is weeks before delivery. This is especially likely if you go called multiple gestation. You might think it would nice to into labor early. have many babies at once, but this may not be good for their health and your health. You may have problems delivering your babies. You will be more likely to need a C-section, which is when the babies How likely is multiple gestation? are delivered through a surgical opening in your belly. Very possible. Depending on the type of fertility treatment used, if more than one follicle is produced, the risk of What can I do to ensure that I reduce the risk of multiple multiple gestation can occur in more than 1 out of 3 births? women successfully getting pregnant. During a fertility treatment cycle when fertility drugs are used with timed intercourse or insemination, your doctor What could happen to the babies? will monitor your cycle very carefully. The use of fertility The babies could be born too early, which is called premature medications will make your body produce more eggs than birth. Half of all twins and 90% of all triplets are born pre- usual.
    [Show full text]
  • Breast Cancer in Young Women
    Breast Cancer in Young Women Oreste Gentilini Ann H. Partridge Olivia Pagani Editors 123 Breast Cancer in Young Women Oreste Gentilini • Ann H. Partridge Olivia Pagani Editors Breast Cancer in Young Women Editors Oreste Gentilini Ann H. Partridge Breast Unit, San Raffaele University and Dana–Farber Cancer Institute Research Hospital Department of Medical Oncology Milan Harvard Medical School Italy Boston, MA USA Olivia Pagani Geneva University Hospitals Swiss Group for Clinical Cancer Research (SAKK) Institute of Oncology of Southern Switzerland Bellinzona Switzerland ISBN 978-3-030-24761-4 ISBN 978-3-030-24762-1 (eBook) https://doi.org/10.1007/978-3-030-24762-1 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made.
    [Show full text]
  • Demystifying Infertility Fundamentals, Tests, Treatment, Medications
    Demystifying infertility Fundamentals, Tests, Treatment, Medications Click to continue Specialty Pharmacy ? Welcome to fertility education: Demystifying infertility This section provides an overview of Fundamentals infertility, including the fundamentals, Diagnostic testing medications, testing, treatment Treatment options options, and additional information. Medications Select any of the topics on the right Additional information for more information. References Terms of use Main menu > Fundamentals ? Fundamentals Select any of the topics for more information. Fundamental questions Female anatomy Male anatomy Reproductive cycle Causes of infertility References Terms of use Main menu > Fundamentals > Fundamental questions ? Fundamental questions What is infertility? Whom does infertility affect? Infertility is defined as not being able to become pregnant after Infertility can affect women or men individually or as a couple regular unprotected (without contraception, like condoms or oral with 1 of 7 couples having trouble getting pregnant during their birth control) sexual intercourse.1,2,3 childbearing years.1 About 10-15% of couples have a medical condition that interferes with conception.2,3 • 1 year if < age 34 • 6 months if > age 35 Causes: • Female related 30-40%2,3 • Male related 20%2,4,5 • Both 30-40%2,3,5 • Unknown 10%1,3 Continued > References Terms of use Main menu > Fundamentals > Fundamental questions ? Fundamental questions Does age matter? Additional resources Women • Booklet: Infertility: An Overview Most fertile in their 20’s to early 30’s • Age and Fertility- A Guide for Patients • Age 30 - Healthy women have a 20% chance of becoming pregnant each month • Age 40 - Healthy women have a 5% chance of becoming pregnant each month The decline of female fertility happens because both the quality and the quantity of eggs gradually decline as a woman ages.6 Men There is no maximum age at which a man cannot father a child.
    [Show full text]
  • Recent Advances in Fertility Preservation and Counseling for Reproductive-Aged Women with Colorectal Cancer: a Systematic Review Lisa M
    CURRENT STATUS REVIEWS Recent Advances in Fertility Preservation and Counseling for Reproductive-Aged Women with Colorectal Cancer: A Systematic Review Lisa M. Shandley, M.D., M.Sc.• Laurie J. McKenzie, M.D. Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia BACKGROUND: The incidence of colorectal cancer RESULTS: There are limited data regarding the impact among reproductive-aged women is increasing. Concerns of colorectal surgery on fertility. The gonadotoxic effects regarding future fertility are secondary only to concerns of chemotherapy on reproductive capacity depend regarding survival and may significantly impact quality on age at the time of chemotherapy administration, of life among reproductive-aged female cancer survivors. cumulative chemotherapy, radiation dose, type of agent, Fertility preservation counseling reduces long-term regret and baseline fertility status. Chemotherapy-induced risks and dissatisfaction among cancer survivors. Health care for colorectal cancers are considered low to moderate, providers counseling patients with colorectal cancer must whereas pelvic radiation with a dose of 45 to 50 Gray understand the impact of cancer treatment on future induces premature menopause in greater than 90% of reproductive potential. patients. Ovarian transposition may reduce but not eliminate the damaging effect of radiation on the ovaries. OBJECTIVE: This review aims to examine the effects that Embryo and oocyte cryopreservation are considered colorectal cancer treatments have on female fertility and standard of care for women desiring fertility preservation, summarize existing and emerging options for fertility with oocyte cryopreservation no longer being considered preservation. experimental. Ovarian tissue cryopreservation remains DATA SOURCES: EMBASE, National Library of Medicine experimental but may be an option for select patients.
    [Show full text]