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1、 South Florida Womans Health Associates Patient Informed Consent FormHCG Weight Loss ProgramPurpose:This Informed Consent Form is intended to give fair notice of the requirements of patients seeking to participate in the HCG Weight Loss Program at SFWHA, to fully disclose any risks associated with p
2、articipation in the HCG Weight Loss Program, and to obtain written “Informed Consent” from the patient to undergo treatment.Historical Applications:HCG was used in the treatment of obesity disorders by a British doctor and PhD. ATW Simeons of the renowned Salvator Mundi International Hospital in Rom
3、e, Italy over a 16 year period commencing in the mid 1950s. Dr. Simeons concluded that HCG (“Human Chorionic Gonadotrophic”) Hormone when used for weight reduction and concurrent with a regimented low calorie diet, not only resulted in significant weight loss from targeted areas where fat deposits w
4、ere likely to collect, but also improved the lipolytic functions of the body when co-utilized with dietary protein sources. Dr. Simeons hypothesized that HCG, which is produced in the female body in large quantities during pregnancy and in quantities ranging anywhere from 5000mlU/ml to 288,000mjU/ml
5、, had a significant role in not only producing a healthy placenta for the fetus to survive, but also had a role in metabolizing fats deposits from the mothers subcutaneous fat stores as an additional food source for the fetus. Dr. Simeons theorized that by giving daily injections of small amounts of
6、 HCG concurrent with a controlled low calorie diet, that the HCG would mobilize the fat into the blood stream where protein and various enzymes could exercise their lipolytic functions (lipolytic means to break down fats usually for the consumption of energy: Dr. Simeons clinic had a 97% success rat
7、io.A number of medical authorities have since supported the theories advanced by Simeons. IN “Medicine and Science in Sports and Exercise” (19:5, sec 179-190, 1986), Dr. Layman, MD Affirmed that the intake of high dietary protein (1) aided in the metabolism of the free floating fat, (2) enhanced inc
8、reased muscle mass, (3) preserved protein composition in organs, (4) stabilized the blood glucose levels, and (5) enhanced the production of human growth hormone from the pituitary gland. Accord in J Am Coll Nutr 2004 Dec. 23 (6:Suppl) 631S-636SNevertheless in spite of these findings by specialized
9、experts in the field of Preventative Health Care, the American FDA requires the following disclaimer:“This weight reduction treatment includes the useof HCG, a drug which has not been approved by theFood and Drug Administration as safe and effectivein the treatment of obesity or weight control. Ther
10、e is no substantial evidence that hCG increases weight loss beyond that resulting from calorie reduction, thatit causes a more attractive or “normal” distribution offat, or that it decreases the hunger and discomfortassociated with calorie restricted diets.”Risks and DiscomfortsBelow is a list of ri
11、sks and discomforts that may be experienced by a small part of the population, in particular, those patients that are already predisposed to allergies, the latter conditions caused by a hyper stimulation of the hormone heparin within the body. The patient should inform their primary health provider
12、if any of the following conditions occur:Allergic Responses If you experience allergic reaction to other substrates, you may have sensitivities to HCG. It is required that you stop using HCG and report your allergic response to you provider immediately. The following are signs of an allergic reactio
13、n: Hives Difficulty breathing Swelling of your face, lips, tongue, or throatBefore receiving HCG tell your provider if you are allergic to any drugs or medications or if you have: A thyroid or adrenal gland disorder An ovarian cyst Cancer or a tumor of the breast, ovary, uterus, prostate, hypothalam
14、us, or pituitary gland Undiagnosed uterine bleeding Heart disease Kidney disease Epilepsy Migraines AsthmaIt is necessary for the provider to know these predisposed pathologies in order to rule out conditions that may not be related to the HCG.Also in allergic responses, the body overproduces fibrin
15、 which induces blood clotting, a potentially lethal situation. Call your healthcare provider immediately if you have any of these signs of a blood clot: Pain Warmth Redness Numbness Tingling in your arm or leg Confusion Extreme dizziness Severe headache Nausea and/or vomiting Urinating less than normalLess Serious Side Effects May IncludeLess Serious side effects may occur from the change in dietary patterns, until the blood sugar levels stabilize.These less serious side effects include Headaches (diet re
