Application Form (Version 3.7)

Application Form
(Version 3.7)

Surname, name:

Date of birth:

Street address:

Postal code, City:

Telephone (day time):

Mobile phone:

E-mail:

E-mail 2:

Occupation, profession:

Employer, function/role:

Current date:

Dear Sir or Madam,

Would you please be so kind and answer the following questions as completely and accurately as you can. The questionnaire takes about 30 minutes to complete.Filling out the questionnaire give you and us valuable information about the causes of your overweight. We use your answers to assess whether you can be approved for our weight reduction program or not. We do only want to allow those clients / patients to whom we have a high chance of success. Or we will recommend you further to an alternative treatment method that is more appropriate for your personal situation.

What are your ideas about a permanent weight reduction?

Ideal weight: kgHabitual weight: kg Height: cm

Habitual BMI: kg/m2

(BMI = Weight in kg / height in m / height in m, e.g. 120 kg / 1.72 m / 1.72 m = 40, 6 kg/m2

Your main motivation factors for weight reduction:
(e.g. health/illness/risk of accident,personal well-being, appearance / attractiveness, partner / professional chances, desire of someone else, more freedom/ new opportunities ...)

How much is a sustainable weight reduction worth?

(e.g. is it more important than jewellery, a holiday trip, a new car?)

Conservative therapy, only with nutritional changes Yes No

Nutritional changes with the support from medicines Yes No

Obesity surgery (Bariatric surgery) Yes No

If you are interested in a surgical procedure, the following requirements must be met by the health insurance:

Age:between 18 and 60 years old

BMI:35 or more (at a height of1.80 m, from 113 kg)

Comorbidities:e.g. diabetes, hypertension, joint pain, etc.

Overweight:for at least 5 years

Diet experiencesat least for 2 years in professional guidance

What is your imagination of a lifelong change in your dietary patterns?

What would be acceptable/ not acceptable?

What would your life partner/ spouse do to support your lifelong dietary and nutritional change? (ask him/ her)

What would be acceptable/ not acceptable?

Are you prepared to conduct more exercise/ sport? How much?

What hobbies have you always wanted to start/ delve into?

Do you feel discriminated because of your body size/ overweight?

In the street Yes No

At workYes No

PrivateYes No

Other perceived disadvantages of your overweight?

Family Anamnesis

Who in your family is overweight?

Father / Brother
Mother / Sister
Grandmother, on the paternal side / Son
Grandfather, on the paternal side / Daughter
Grandmother, on the maternal side / Uncle
Grandfather, on the maternal side / Aunt

Please name other overweight people in your environment (family, neighbours, local acquaintances, current and former school / work colleagues):

Are any of these illnesses present in your family? (Please tick all the boxes that apply):

Blood sugar (Diabetes mellitus).If so, who?
Type 1 (already as a child)
Type 2 (Elderly illness)
Hypertension
Myocardial infarction (heart attack)
Apoplexy (stroke)
Hypercholesterolemia(High levels of blood lipids)
Eating disorders (Bulimia, Anorexia)
Depression
Cancerous diseases
Who? What?

Personal Anamnesis

Your weight development

Were you already overweight as a child? Yes No

Were you already overweight as an adolescent? Yes No

When did the weight gain begin (after pregnancy, after marriage, after the menopause, at the beginning of employment, change of position, divorce, etc.), and can you give an explanation?

Do you suffer from any of the following symptoms?

Diabetes Mellitus Type 2 (Elderly illness) Yes No

Progressive dyspnoea (Shortness of breath) Yes No

Arterial hypertension (high blood pressure) Yes No

Other cardiovascular diseases (myocardial infarction, angina pectoris)Yes No

Dyslipidaemia, hypercholesterolemia (high levels of blood lipids) Yes No

Increased amount of uric acid/ goutYes No

Thrombosis, embolismYes No

Oedema (water retention) Yes No

Reflux disease (acid eructation)Yes No

Incontinence (uncontrolled loss of urine or faeces)Yes No

Back painsYes No

Hip ailmentsYes No

Gonalgia (knee pain)Yes No

Ankle painYes No

Heel painYes No

Depressive moodsYes No

AllergiesYes No

If so, against what?

For women only:

PCOS (Polycystic Ovary Syndrome)Yes No

Have you been pregnant?Yes No

Weight gain per pregnancy? kg

Regarding the diseases above, who is treating it, your GP or a specialist?

(First name and surname, place)

What type of surgical interventions has been done so far (Doctor, type of surgery, year)?

Do you smoke? Yes No

If yes, how many packs a day?

If no, were you a smoker? Yes No

If yes, how many packs a day?

Alcohol? Yes No

If yes, what is your average intake per week?

Beerdl/week (1/2 pintis 2.36 dl)

Winedl/week (1 glass is ca. 1 dl)

Other alcoholic beveragesdl/week

Other addictive substances? Yes No

If yes, which?

If no, earlier? Yes No

If yes, when did you stop? What was the amount per day?

Medical anamnesis

(Absolutely ALL regularly taken medicines, e.g. also oral contraception = birth control)

Name / Mg / Tablets, effervescent, powder, drops,… / Dosage
(Morning-noon-evening)
e.g. Cosaar / 5 mg / Tablets / 1-0-0

Exercise/ movement anamnesis

Number of hours per day
On
weekdays / On
weekends
1. Level
Sleeping
2. Level
Slow walking, office work, light housework, knitting,etc.
3. Level
Painting the house, lifting light objects, truck driving, lawn mowing, cleaning windows, dancing, hiking, swimming, ping-pong, etc.
4. Level
Physical work, construction work, joinery/carpeting, tennis, disco, etc.
5. Level
Hard work, wood chopping, carrying heavy loads, jogging, football, etc.
Total / = 24 hours / = 24 hours

Nutrition anamnesis/ Food diary(What do you eat on normal workdays?)

Breakfast
(e.g. 2 cups of coffeewith cream, tea, sugar, lemon, 2 rolls, ca 20g of butter, 1 ts jam, etc.)
During the morning
(e.g. 1 fruit yogurt, 1 piece of fruit, 1 chocolate bar, etc.)
Lunch
(e.g. normal menu, with sauce, soup, without dessert, in a restaurant, in the canteen, only 1 sandwich, portion (restaurantportion, plus a second serving? etc.)
During the afternoon
(e.g. biscuit, cake, chocolate, fruit, yogurt, etc.)
Evening
(e.g. at home, rather than in the restaurant, it is faster, a complete menu, rather cold, bread, butter, cheese, salami, ham, etc.)
Later, during the evening?
(e.g. chocolate, biscuits, nuts, crisps, fruit, yogurt, bread, cheese, sausages, etc.)

Fluid intake

Less than 1 litre per day / Given in dl per day
1 to 1.5 litre per day / Mineral, ZERO-beverages
1.5 to 2 litre per day / Tea, coffee
2 to 2.5 litre per day / Milk
3 and more per day / Apple juice, fruit juices/squashes
Soft drinks
Other:

General information about your eating habits?

Do you feel unwell because you have eaten an unusual greater amount? Yes No

Are you afraid to lose control of your food intake?Yes No

Have you lost more than 6kg in the 3 recent months?Yes No

Do you consider yourself too fat, whereas others will describe you as too thin? Yes No

Do nutrition and food dominate your life? Yes No

Do you tend to have a sweet tooth? Yes No

Do you have an increased appetite before your period? (Women only) Yes No

Do you suffer from binge eating? Yes No

(uncontrolled, fast intake of very large quantities,

with a sudden unpleasant feeling)

Do you reward yourself with food when feeling frustrated, stressed, sad or pleasure? Yes No

Can you continuously eat without feeling saturated? Yes No

Do you eat another meal at night? Yes No

Are you aware of the fat content when cooking? (butter, oil, cream etc.) Yes No

Are you a fond of herb butter, mayonnaise and mustard? Yes No

Do you regularly eat breaded, fried or gratinated foods? Yes No

What food style appeal to you?

Sort by priority (1 to 6)

a) Big Eater /Gorger

i.e. They like to eat and enjoy. The natural saturation feeling is out of balance or it is missing completely. This feeling has to be re-balanced.

b) Sweet Eater

i.e. They usually eat normal quantities at the table, but do snack a lot in between the meals. Stress and frustration causes them to consume a lot of sweets.

c) Fat Eater

i.e. They love foods that are solid (hefty) and savoury. This is often pure habits and can be adjusted in small steps. Small steps are necessary because fat-rich foods are particularly rich in taste and the palate can only gradually get used to finer, lighter foods.

d) Nibbler/Grazer/Snack Eater

i.e. They eat many times a day and this is not because they are hungry, but out of lust and habit. Their eating habits are uncoordinated, they do not notice in what amounts they eat. They do not have time to cook and often eat while standing or walking.

e) Night Eater

i.e. They wake up at night with a with a ravenous hunger. The background and tendencies are similar to the sweet eater or the nibbler.

f) Binge Eater

i.e. They suffer from munchies/ episodes of food binging, to the extent of consume very large amounts of food in a short time. They then have a guilty conscience and are the feeling of failing. They usually wait too long to eat the food, they have enormous, ravenousappetite later.

Analysis of the Nutritional Process

Who does the grocery shopping at home:

Who cooks in the evening:

Who eats with you in the evening:

Food preferences of the family members:

Where do you eat during the day (on working days):

How often does it happen that you nod off or fall asleep?

(never = 0, rarely = 1, occasionally = 2, often = 3)

Pathological result for total value> 10

While reading

Watching television

In theatre, in the audience

As passenger in the car (< 1h)

Laying down in the afternoon

When speaking (sitting)

Sitting, without eating (without alcohol involved)

When driving, as you stop in front of the red light

Total value of points:

Diets

It is important to know your diet history, in order to assess your weight problem correctly.

The information about the diets should complete/answer the list of points below:

• When? (Month/Year)
• Duration? (in weeks, months, years)
• What was done? (reduction of fat, low carb, medications, etc.)
• By who? (Doctor, nutritional advisor, Weight Watchers, etc.)
• How much weight did you lose?
• How much weight did you later gain?
• What was the price of the program?

Year / Duration of the diet / Which diet? / Doctor, nutritional advisor, Weight Watchers, etc. / Weight loss (indication of habitual and final weight) / Subsequent weight gain with time / Approx.cost
e.g. 1990 / 6 months / Weight Watchers / Weight Watchers / 95 kg => 87 kg,
8 kg weight loss / 10 kg, within 9 months / CHF 500.-

Dietary Change-course

(Condition as of January 2017 - subject changes reserved)

What type of treatment do you prefer (medical care for two years)?

Group courses(CHF 140.-/month pp)– incl. exchange of experiences and motivation in groups of 5-15 participants (fixed dates)

Individual-/pair treatment(CHF 140.-/month pp) – incl. 7-10 shorter individual meetings + telephone sessions (flexible with time and place)

Company courses(up on request)

The supervisions mentioned above include:

O Preliminary individual medical examination (analysis of questionnaires)
O Course methodology (130 slides) on the latest research within conventional medicine
O Monthly newsletters by e-mail, containing seasonally adjusted recipes
O Excl. any medication and medical assistance (usually paid by health insurance companies)

I would like to reduce the course duration to a 12 months’ period. This is possible if the reduction to your normal weight (BMI <25) is less than 10%. Thus, the total cost of the course is cut in half.

Name/e-mail of the spouse/life-partner

(The newsletter including the recipes, will be sent to you by e-mail to you and your spouse / life partner. The main goal is for you to discover new favourite food together - these recipe suggestions are included in the course fees, thus no additional costs for the recipient. It can be cancelled at any time).

I am able to attend the evening course on the following days:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday (during the day)

At which location would you like to attend the course? Courses are held in: Aarau, Basel, Berne, Cham, Chur, Wetzikon, Winterthur and Zurich

Method of payment

Prepayment with 2% discount: we will send you an invoice with the total amount - 2% discount for settlement within 30 days

Standing order with monthly transfers: we will send you a form which you can fill out and forward to your bank / post office.

Cancellation or discontinuation of the course is possible upon request concerning mandatory cases (for example relocation, stay abroad, pregnancy or in the event of an absent weight loss). The course fee would have to paid otherwise. We do therefore recommend to not start the course if such an event or interruption is already conceivable.

Recommendation

How did you hear about this course?

Was the course recommended by a current participant? If so, by whom?

Would you like to invite other acquaintances/ relatives/ neighbours/ colleagues to join this course? If so, who?

• Names of the people, that you contact yourself
• Names and e-mail of the people whom we should contact and send the course documents to

General remarks:

Next steps:

• Please e-mail the completed registration questionnaire to
• Alternatively by mail to Rebalance,Attn:Christine Heger, Sandstrasse 25, 5412 Gebenstorf

Confirmation

By completing and submitting this assigned questionnaire to one of the addresses above, I hereby agree to the following points:

§A contractual relationship with Rebalance AG with a successful course approval and cooperation;

§The information given on this registration questionnaire is correct, complete and true;

§That Rebalance AG will treat all the information about you confidentially,and only disclose it to third parties (for example, general practitioners) if they are obliged by the professionals or the contract due to the confidential treatment of the information submitted

Many thanks for completing this questionnaire. Our medical admission office will evaluate it carefully. We will keepyou informed about our decision of approval. If we discover that it might be difficult for the participant to achieve a high long-term success rate, we will then guide youfurther for amore suitablealternative method in order to reach a sustainable weight loss.

Best regards,

Your Rebalance Team

Dr. med. Marc Fouradoulas, Zürich

Prof. Dr. med. Franz Hering, Meggen (LU)

Dr. med. Beatrice Hofmann, Zürich and Wetzikon

Dr. med. Bruno Kesseli, Cham

Dr. med. Barbara Padberg Sgier, Chur

Dr. med. Nadja Pecinska, Zürich und Basel

Dr. med. Silivia Puglia, Zürich

Dr. med. Simone Rohrbach, Kriens (LU)

Nutritionist, Henriette Saevil, Zürich

Dr. med. Martin Sonderegger, Winterthur

Dr. med. Alex Stalder, Bern und Basel

Dr. med. Gabriela Stöckli, Aarau

Dr. med. Lucie Tlach, Chur

Dr. med. David Infanger, Zürich

Christine Heger, Head of Administration & Communication

Willy Bischofberger, President