Bariatric Surgery New Patient Packet · Married Separated PATIENT DEMOGRAPHICS Patient Name:...

PATIENT DEMOGRAPHICS

Patient Name: Mr./Mrs./Ms./Dr. ___________________________________________________ Date: _____________________

Age: _____________ Date of Birth: _________________________ Gender: _____ Male _____ Female

Address: ____________________________________________________________________________________________________

Email: _________________________________ Social Security: _________________ Drivers License #: _____________________

Phone –Home: _________________ Mobile: __________________ Work: __________________ Fax: ____________________

Race (Optional): African American Asian Caucasian Hispanic Native American/Alaska Native Native Hawaiian/Pacific Islander Other____________________________________________

Marital Status (Optional): _____ Single _____ Married _____ Divorced _____ Widowed _____ Separated

Employment Status: Full Time Part Time Self Employed Homemaker Student Retired Disabled Unemployed

Employer Name: ________________________________________ Employer Address: ____________________________________

Employer Phone: _________________ Employer Fax: _______________________ ____________________________________

INSURANCE VERIFICATION

Primary Insurance Company: ______________________________________ Primary Insurance Phone: _______________________

Primary Insurance Address: ____________________________________________ IPA/Medical Group: _______________________

Insured’s Name: ________________________________________________ Insured’s Social Security #: _______________________

Relationship to Patient: __________________________________________ Insured’s Policy Number: ________________________

Insured’s Employer: _____________________________________________ Insured’s Group Number: _______________________

Secondary Insurance Name: ______________________________________ Secondary Insurance Phone: _____________________

Secondary Insurance Address: _____________________________________ Insured’s Policy Number: ________________________

Insured’s Name: ________________________________________________ Insured’s Group Number: ________________________

PRIMARY PHYSICIAN AND REFERRING PHYSICIAN

Primary Care Physician Name: _____________________________________________ Physician Phone: ______________________

Physician Address: _________________________________________________________ Physician Fax: ______________________

Referring Physician Name (if other than Primary Care Physician): _______________________________________________________

Bariatric Surgery -- New Patient Packet 1

Physician Address: _________________________________________________ Phone: _______________ Fax: ________________

Specialty: ___ Endocrinology ___ Cardiology ___ Gastroenterology ___ Pulmonology ___ Gynecology ___ Orthopedics ___ Hepatobiliary ___ Transplant ___ General Surgery Other___________________

FAMILY HISTORY

Please indicate the age of each family member, or age at time of death and ALL medical problems they suffer(ed).

Family Member Living (Age) Deceased (Age) Medical Problems

Mother

Father

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Brother/Sister

Brother/Sister

Brother/Sister

Brother/Sister

SOCIAL HISTORY

Do you currently smoke? Yes No Did you smoke in the past? Yes No Date last smoked _________________

How many packs per day do/did you smoke? _____________ How many years total have you smoked? ________________

How much alcohol do you drink? (Please indicate 1-3, 4-6, 10+ beverages)

Daily Weekly Monthly

Beer

Wine

Liquor

Have you ever used drugs? Yes No Are you currently using drugs? Yes No Please specify __________________________

Have you ever used intravenous drugs? Yes No Please specify ____________________________________________________

ALLERGIES AND CURRENT MEDICATIONS

Are you allergic to any medications? Yes No If yes, please specify:

Medication Name Allergic Reaction Medication Name Allergic Reaction

Are you allergic to: Surgical Tape Latex Iodine Please specify type of reaction ________________________________

Pharmacy: ______________________________ Address: ___________________________ Phone: _________________________


____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Please list ALL your current medications and dosages. Attach another sheet if necessary.

Medication Name Dose Frequency Medication Name Dose Frequency

Do you take any blood thinning agents (Aspirin, Coumadin, Plavix, Lovenox etc.)? Yes No Please Specify __________________

Do you regularly take laxatives? Yes No Please Specify ____________ Are you currently on birth control medication? Yes No

Please list all vitamins, herbal supplements or minerals that you currently take:

Do you take all your medications as prescribed? Yes No If No please specify why not.

SURGICAL HISTORY

Please check the procedures you have had done and indicate the month and year: ____ Colonoscopy (___/___) ____ Mammogram (___/___) ____ Pap smear (___/___) ____ Prostate exam (___/___)

Please list all surgical procedures and the date they were performed:

MEDICAL HISTORY

Please indicate which of the following conditions you have been diagnosed with, the year of diagnosis and if you currently take medications for that condition:

Medical Condition Yes No Year Diagnosed

Meds Medical Condition Yes No Year Diagnosed

Meds

Diabetes – Diet controlled GERD (reflux disease)

Diabetes – Non insulin dependent

Hiatal Hernia

Diabetes – Insulin dependent

Polycystic Ovarian Syndrome

Gestational Diabetes Thyroid disease

Diabetic Neuropathy Kidney disease

High Blood Pressure Urinary Incontinence

High Cholesterol Osteoarthritis

High Triglycerides Rheumatoid Arthritis

Coronary Artery Disease Sleep Apnea CPAP BiPAP

Congestive Heart Failure Asthma

M.I. (Heart Attack) Pulmonary Hypertension


Medical Condition Yes No Year Diagnosed

Meds Medical Condition Yes No Year Diagnosed

Meds

Atrial Fibrillation COPD / Emphysema

Heart murmur or Anemia palpitations Blood disorders

Abnormal EKG DVT

Angina (Chest Pain) PE (Pulmonary Embolism)

Coronary Bypass surgery Lupus

Coronary Angioplasty or Stent

Crohn’s disease

Stroke Ulcerative Colitis

Depression Irritable Bowel Syndrome

Anxiety Liver Cirrhosis

REVIEW OF SYSTEMS

Please indicate if you have ever in the past or currently have the following issues.

GENERAL, HEAD, EYES, EARS, NOSE, THROAT

Never Past Now

RESPIRATORY

Never Past Now

Generalized weakness Cough

Chronic fatigue Wheezing

Fever Bloody cough

Chills Shortness of breath at rest

Night Sweats Pneumonia

Double vision Bronchitis

Visual disturbances GASTROINTESTINAL Blurred vision

Corrective lenses: circle one Contacts Glasses Heart burn or acid indigestion

Hearing problems: please specify

_________________________________________

Frequent burping or regurgitating food

Ringing in the ears (Tinnitus) Frequent coughing/choking at night

Sinus infections or problems Frequent diarrhea

Nose bleeds Chronic constipation

Neck masses Fecal incontinence

Neck pain Hemorrhoids

Difficulty swallowing Vomiting blood

CARDIOVASCULAR Black or tarry bowel movements

Hepatitis or liver cirrhosis

Chest pain Fatty liver disease

Heart Murmur Pancreatitis

Palpitations or Arrhythmias Gallstones

Heart Attack: month/year____________ Irritable bowl

How many blocks can you walk without stopping to catch your breath? _______

Bright red blood in bowel movements

Pain in calves or buttocks when walking, relieved by rest

Colitis: circle one Infectious Crohn’s Ulcerative


Never Past Now Never Past Now

Shortness of breath when climbing stairs GENITOURINARY Varicose veins

Thrombophlebitis Burning or pain with urination

Scaly and thick skin on lower extremities Frequent urination

Lower extremity ulcers Blood in urine

INTEGUMENTARY Prostate problems: specify year last PSA level done _________

Frequent infections Leakage of urine with laughing, coughing, or sneezing Hair loss

Brittle nails Kidney stones: month/year________

Excessive sweating NEUROLOGIC

HEMATOLOGICAL Stroke

Excessive or abnormal bleeding Epilepsy or Seizures

Excessive or abnormal bruising Double vision

Exposure to AIDS/HIV Headaches: circle one rare occasional frequent severe

Have you ever received a blood transfusion: month/year ________

MUSCULOSKELETAL Never Past Now EMOTIONAL Never Past Now

Sciatica Anxiety

Scleroderma Bipolar disease

Gout Depression

Swollen or painful joints Manic depressive

Hip pain Schizophrenia

Back pain Do you have trouble sleeping?

Lower extremity pain: circle one Knee Ankle Feet

Rate your self esteem level Low Med High

Rate your energy level Low Med High

Lower extremity swelling: circle on Knee Ankle Feet

Does weight affect your life? Circle

one Physically Financially Socially

Weight related injuries: please indicate type

& date of injury _____________________________

Have you ever been emotionally, physically or sexually abused?

FEMALE PATIENTS ONLY Are you usually tired?

Are you easily distracted?

Periods: circle one Irregular Painful Heavy Absent

Have you been hospitalized for psychiatric reasons? Please indicate

reason and month/year of admission ____________________________________

Pregnancies: number of pregnancies ______; number of live births ______

Miscarriage: number ____________ Have you ever seen a Psychiatrist?

Abortions: number _____________ Reason:__________________________________________ Name: ___________________________________________ Address:_________________________________________

Phone number: ____________________________________

Difficulty conceiving

Uterine Fibroids

Ovarian cysts

Are you post menopausal ?

Birth control pills


____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Other contraceptive methods: please specify type ___________________________

Please rate each of the following activities with the level of dozing that you experience:

0 = would never doze 1 = Slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

Obstetric complications: please specify

_____________________________________

Sitting and reading

Watching TV

SLEEPING HABITS Yes No

Sitting quietly after lunch

Sitting and talking to someone

Do you snort or gasp awake at night? Sitting inactive in a public place

Do you snore? Lying down to rest in the afternoon

Do you have daytime sleepiness? In a car, while stopped for a few minutes

Do you have restless sleep or frequent awakening?

Passenger in car for an hour without a break

Has anyone told you that you hold your breath while sleeping?

TOTAL EPWORTH SLEEPINESS SCORE

Please indicate if you have had any of the following studies, the reason for each study and date the study was performed:

Reason for Study Date Reason for Study Date

Sleep Study Cat scan of abdomen

EKG Upper GI study

Stress Test Manometry

Chest X ray EGD

Cat scan of Chest MRI ( indicate type)

PATIENT WEIGHT INFORMATION

Current Weight (lbs): ________ Current Height: _____ft _____inches

My personal target weight goal is __________lbs. I want to lose ______lbs in ______ weeks/months/years (circle one)

Life Event Age Weight Life Event Age Weight

Lowest Childhood Weight Lowest Adult Weight

Highest Childhood Weight Highest Adult Weight

Weight before Puberty Greatest amount of weight loss at one attempt

Weight after Puberty Greatest amount of weight gain

Please describe, in your own words, how you feel this weight loss will change your life:

Weight at start Weight at delivery Maximum post partum weight loss

Pregnancy # 1

Pregnancy # 2

Pregnancy # 3

Pregnancy # 4


Please specify ALL attempted diet programs you have tried in the past or present:

Diet Plan Year Total Weight

Loss (lbs)

Total Weight

re-gained

(lbs)

Duration of Diet

Multiple Attempts

at Diet


Loss (lbs)

Total Weight

re-gained

(lbs)

Duration of Diet

Multiple Attempts

at Diet

Weight Watchers

Phen Fen/Redux

Jenny Craig Xenical

Nutri-System Metabolife

Atkins Diet Meridia

South Beach Diet

Hoodia

Alli

Grapefruit Diet

Amphet-amines

Pritikin Diet Trimspa

Cabbage Soup Diet

Slimquick

Accutrim

T.O.P.S. Dexatrim

Richard Simmons

Hydroxycut

Adipex

Lindora Diet Plan Year Total

Weight Loss (lbs)

Total Weight

re-gained

(lbs)

Duration of Diet

Multiple Attempts

at Diet


Loss (lbs)

Total Weight

re-gained

(lbs)

Duration of Diet

Multiple Attempts

at Diet

Over Eaters Anonymous

Xenadrine

Exercise Program

Cal Ban 3000

Weight loss camps or retreats Medifast

Acupuncture Opti-fast

Hypnosis Slim-fast

Jaw wiring Liquid Diet

Physician Supervised Programs (Please indicate if INPATIENT or OUTPATIENT treatment)


Other Programs or Medications Used: (please list any of the above diets if performed multiple times)

NUTRITION AND EXERCISE INVENTORY

Yes No Yes No

Do you like to cook? Which meals do you most often skip?

Do you eat throughout the day? Do you consider yourself an emotional eater?

Do you skip meals? Do you have cravings?

How often do you cook? _____ Never _____ meals per day ______ days per week

Please indicate how often you eat: Never Daily (specify number) of times a week

Breakfast ________ times a week

Morning snack ________ times a week

Lunch ________ times a week

Afternoon snack ________ times a week

Dinner ________ times a week

Night time snack ________ times a week

Dessert ________ times a week

Fried foods ________ times a week

Fast Food ________ times a week

At a restaurant ________ times a week

Frozen meals ________ times a week


Please Indicate how often you drink the following beverages:

Coffee ______ Never ______ per day ______ days per week

Tea ______ Never ______ per day ______ days per week

Juice ______ Never ______ per day ______ days per week

Soda ______ Never ______ per day ______ days per week

Shakes/smoothies ______ Never ______ per day ______ days per week

Protein drinks ______ Never ______ per day ______ days per week

Sports drinks ______ Never ______ per day ______ days per week

Whole milk ______ Never ______ per day ______ days per week

2% milk ______ Never ______ per day ______ days per week

1% milk ______ Never ______ per day ______ days per week

Skim milk ______ Never ______ per day ______ days per week

Soy milk ______ Never ______ per day ______ days per week

Water ______ Never ______ per day ______ days per week

How physically active are you? Inactive Average/active Very active

How often do you participate in physical activity? ______ Never _______ per day ______ days per week

Do you belong to a gym? (please specify which one) ___________________________ _____ Yes _____ No

What type of activity do you perform? __________________________________________________________________________________________________

Is there anything that prevents you from being physically active? (please specify) ______________________________________________________________________

_____ Yes _____ No

HOW DID YOU HEAR ABOUT US

How did you hear about us: Friend Primary Doctor Television show __________________________________ Online Search __________________________ Other ___________________________________

Have you attended a patient information seminar: Yes No Location_______________________________________________


Bariatric Surgery New Patient Packet · Married Separated PATIENT DEMOGRAPHICS Patient Name:...

Documents

Transcript of Bariatric Surgery New Patient Packet · Married Separated PATIENT DEMOGRAPHICS Patient Name:...