Weight Loss Clinic Patient Forms

New Patients: Please complete the following seven forms labeled in red and either fax them or scan and email them to your first consultation with the doctor:

1) Patient Contact Informationclick to download

2) Patient Questionnaireclick to download

3) Informed Consentclick to download

4) Group Confidentiality Agreementclick to download

5) Notice of Privacy Practicesclick to download


Complete the following questionnaires if they apply to you and bring them with you:

6) Do you snore, are you tired or are you being treated for high blood pressure?click to download

7) Do you have episodes of overeating? click to download


These forms will help you keep track of your progress, choose the one that works best for you:

Calorie and Exercise Log  – click to download

Calorie and Exercise Record  –  click to download

Weekly Log Sheet –  click to download

Weekly Record Sheet –  click to download

Measurementsclick to download

Weight Loss Graphclick to download


Helpful Tools:

First Session Instructions-First Step  –  click to download

First Session Instructions-Better Weighsclick to download

MNP Recipes – click to download

MNP Health One Recipes – click to download  *NEW*

Reasons I Want to Lose Weightclick to download

Taxpayer’s Guide to IRS Policy to Deduct Weight Control Treatment – click to download

Food Choices – click to download

Nutritional Informationclick to download

Vegetable and Fruit Calories, sorted by calorie amountclick to download

Vegetable and Fruit Calories, sorted alphabeticallyclick to download

Torani Syrups, sugar-free – click to download

Loss of Visceral Fat with Weight Lossclick to download

BMI Chart-click to download

We are a physician supervised weight loss program and medical diet program serving clients serious about losing weight and keeping it off in Northern California and the south San Francisco Bay Area, including San Jose, Los Gatos, Saratoga, Campbell, Cupertino, Santa Clara, Sunnyvale, Morgan Hill, Gilroy, Hollister, Mountain View, Los Altos, Palo Alto, Milpitas, Fremont, and Santa Cruz.