Dear Patient: - LifeBridge Health | Mainlifebridgehealth.org › Uploads › Public › Documents...

LifeBridge HealthDivision of Bariatric Surgery

5401 Old Court RoadRandallstown, MD 21133

Dear Patient:

Thank you for inquiring about our weight loss surgery program! The decision to undergo weight loss surgery is not a decision you made quickly; in a similar fashion, the process of preparing you for surgery also cannot occur quickly, nor be rushed. Please take the time to fill out the enclosed intake form carefully and completely. Remember to attach a legible copy of your picture ID along with your medical insurance card (front & back). Our staff will then contact you to give you an appointment date, usually within two weeks of receipt of your application.

In the meantime, we encourage you to attend our monthly informational seminars and/or webinars. We will be present at each seminar, as well as, members from our staff and post-op patients. Everyone is invited to attend, be sure to verify the dates on our website at www.lifebridgehealthweightloss.org or call (410) 601-4486.

Most insurance companies require that policy holders be seen monthly for 3-6 consecutive months to document weight loss attempts and progress. Therefore, as an insurance and program requirement we require patients to see the Registered Dietitian at either Sinai Hospital or Chartwell Professional Center. Adherence to the program greatly increases your success following bariatric surgery. Both programs adhere and teach the same nutritional information concerning food choices and surgery

Prior to being seen at one of the LifeBridge Health centers ask your Primary Care Physician (PCP) for a request for consultation. If a referral is required with your insurance plan, please make sure we have an updated referral on file. All co-payments are due at the time of service. PLEASE NOTE we only accept cash, Visa, and/or MasterCard for payment at Sinai Hospital. We only accept cash or checks at our other locations.

Your insurance plan will likely require extensive testing to ensure that they will approve the surgery. If you prefer, you can obtain some of this BEFORE your initial consultation. The following are required by ALL insurance companies of all patients prior to scheduling surgery:1) Proof of attendance at a minimum of one of our bariatric seminars or webinars.2) A letter from your primary care physician. This letter should summarize your diet history, your obesity-

related medical problems and any physician-supervised weight loss attempts that you have had. It should also include a sentence or two stating that your physician feels that you are a good candidate to undergo surgery.

3) Psychology/psychiatry clearance. All patients are required to undergo a psychological evaluation prior to surgery, so that we can document adequate knowledge of the procedure, reasonable weight loss expectations, and the ability to comply with the rigorous dietary restrictions post-operatively. You can obtain clearance from your own psychologist or psychiatrist if you prefer.

Every patient will require additional pre-operative testing, these tests will be ordered on an individual basis after you have met with one of the surgeons. If you have any questions about LifeBridge Health Bariatric Surgery Program and our locations, please contact us at 410 601-4486 and one of our staff will be glad to help you.

We look forward to meeting you and helping you reach your goal of a healthy weight and healthier lifestyle.

Christina Li, MD, FACS Celine Richardson, MD. FACS

410-601-4486 (office) 410-601-9014 (fax)Web Site:www.lifebridgehealthweightloss.org E-mail: [email protected]

(updated on 1/09/2015)

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mailto:[email protected]



****KEEP THIS PAGE***AVOID these medications 2 weeks prior to surgery and

call the office before taking any new medication for pain management

Aspirin Products:AggrenoxAlka-Seltzer (Effervescent pain reliever and antacid, lemon-lime effervescent pain reliever and antacid, extra strength effervescent pain reliever and antacid, Morning relief)Anacin (maximum strength)Ascriptin (enteric regular strength, regular strength, arthritis pain)AsperDrinkAspergumAspirin/butalbital/caffeineAspirin with buffersAspirtabAspir-TrinBayer (Children’s Chewable, Adult Low Strength, Genuine Bayer, regular strength caplets, women’s aspirin plus calcium caplets, extra strength back and body pain)BC Powder (arthritis strength)Bismuth Subsalicylate (Pepto Bismol, Kaopectate, Bismatrol, Kola-Pectin, Diotame, Kapectolin, Bismate, Bismakote, Bismuth, Stomach Relief, Kao-Tin, Kensorb, Kao-Paverin, Peptic Relief, Sootheze)Bufferin (arthritis strength, extra strength)Carisoprodol Compound (with codeine)Citrated/Aspirin/caffeineCopeDamason-PEasprin

Aspirin Products:Ecotrin (Adult Low Strength, Maximum Strength)EcprinEndodanEntercoteEquagesicExcedrin (extra-strength, migraine)FiorinalFortabsGelprinGenacoteGoody’s (body pain formula powder, extra strength headache powders, extra strength pain relief tablets)HalfprinOrphenadrine P-A-C analgesicMagnesium salicylate (Doan’s, Backprin, Keygesic, Momentum, Agesic, Mobidin, Novasal, Pamprin)Magnaprin (Improved, arthritis strength)MicraininMiniprinNorgesic (Forte)Norwich AspirinPamprinPercodanRobaxisalSomaStanback PowderSt.Joseph (Adult Low Strength chewable, Adult Low Strength enteric coated tablets)Store brands (Good Neighbor Pharmacy, Good Sense, Leader, Medi-First, Quality Choice, Top Care, Rite Aid)

Synalogos-DCTrilisateVanquishZorprin

NSAIDS products:Diclofenac (Flector, fcataflam, Voltaren, Arthrotec, Cataflam, Cambia)Diflunisal (Dolobid)Etodolac (Lodine)Fenoprofen (Nalfon)Flurbiprofen (Ansaid)Ibuprofen (Advil, Motrin, Genpril, Haltran, Menadol, Midol, Vicoprofen, Dristan)Indomethacin (Indocin)Ketoprofen (Oruvail, Orudis)Ketorolac (Toradol, Acular, Acuvail, Sprix)Meclofenamate Mefenamic (Ponstel)Meloxicam (Mobic)Nabumetone (Relafen)Naproxen (Naprosyn, Prevacie Napra PAC, Aleve, Naprelan, Anaprox)Oxaprozin (Daypro)Piroxicam (Feldene)Salsalate (Disalcid, Amigesic, Salflex, Persistin, Mono-gesic, Marthritic, Arthra-G, Argesic-SA)Sulindac (Clinoril)Tolmetin (Tolectin)

Cox-2 InhibitorsCelecoxib (Celebrex)



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****KEEP THIS PAGE****Application Process

1. Call your insurance company and complete the Insurance Verification form on page 4.

2. Complete the Patient Application on pages 5 - 13 and the Nutritional Assessment on pages 15 – 18.

3. Return the Insurance Verification, Patient Application, and the Nutritional Assessment to our office (pages 4 – 18). a. Please keep the folder & resource papers in the right sleeve.

4. Our office staff will verify your insurance benefits.5. One of the physicians will review your application.6. Our office staff will call you to schedule an initial appointment with

the physician and dietitian.a. Reminder: the nutritional consultation has a mandatory program

fee (not covered by any insurance) which is due at the initial appointment.

b. All self-pay portions are due at the time of service.c. We accept only cash or credit cards as payment. We do not

accept checks.7. Please allow 1-2 weeks, plus mailing time for our staff to contact

you.8. While waiting to hear from our office you can complete the

following steps:a. Contact your Primary Care Physician for any necessary referrals

per your insurance requirement. (Some offices require 1-2 weeks notice to have referrals ready).



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b. Attend one of our bariatric seminars/webinars (see enclosed flyer for dates).

Please include copy of driver’s license and insurance card (front & back) with

application



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Insurance Verification FormCall to verify insurance coverage for bariatric surgery. The telephone number is located on the back of your insurance card. This completed form must be submitted with your application.

First Name:

Middle Initial:

Last Name:

Birth Date:

Insurance Company:Insurance Phone No.:Date Insurance Company Called:________________________

Spoke with:_____________________

Type of Plan: HMO

POS PPO

MCO

Medicare

Other: _________________

Policy No.: __________________

Group No.: ________________

Effective Date: _____________

Ask your insurance representative the following questions:

1. Is this a small group policy?Yes

No2. Does this policy have ANY exclusion for Bariatric Surgery or

Morbid Obesity?Yes

No

3. Does the insurance cover the following procedures:a. Gastric Bypass (CPT 43644)b. Gastric Banding (CPT 43770)c. Sleeve Gastrectomy (CPT 43775)

Yes No

Yes No

Yes No

4. Is this procedure subject to any pre-existing conditions on the policy? If yes, please list _______________________________________________________

Yes No

5. Are there specific criteria that need to be met in order to qualify for this surgery? If yes, please list:

a. Total months of consecutive supervised weight lossb. Other: __________________________________________

Yes No _____ months

5. Do you need a referral from your Primary Care Physician to see the specialist?

Yes No

6. Is there a co-pay to see the Specialist?a. What is the co-pay?

Yes No



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$ ___________

7. Do you have a deductible?a. What is the amount?b. How much of the deductible has been met?

Yes No

$ _________$ _________

Please include a copy of your driver’s license and insurance card (front & back) with the application



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Patient Application

NAME: _________________________________ Date: __________________

I am interested in having:-CHOOSE A PROCEDURE -

I am interested in seeing the doctor & dietitian:-CHOOSE A LOCATION -

Gastric Bypass NorthWest Hospital CenterSleeve Gastrectomy Sinai HospitalLaparoscopic Band Dorsey Hall- Ellicott City, MD

First Name: Middle Initial:

Last Name:Gender: M F

Social Security No.:

Birth Date:Current Age:

Weight:

Height:

BMI: (If known)

Mother’s Maiden Name:

Contact Information:Home Address: Apt/Unit #:

City:State: Zip:

E-mail:May we contact you at this number?

Home Number: Yes No Preferred Cell Number: Yes No Preferred Work Number: Yes No Preferred Employed: Yes No Full Part Time Retired



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Time DisabledEmployer: Occupation:Employers Address: Length of time @ current employment: ________ Years ________ Months

NAME: _________________________________

Emergency Contact Information:

Name:Relationship:

Home Address:City, State, Zip:

Home Number: Cell Number : Work Number:

Pharmacy Information:Pharmacy Name: ________________________________________________________________Address: ______________________________

City, State, Zip: ________________________

Phone Number: ________________________

Fax Number: ___________________________

Physician Information:



Primary Care Physician Other Physician

Name:Specialty:Address:Address 2:City:State:Zip:Phone Number:Fax Number:

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NAME: ________________________________

Insurance Information:Primary Insurance Secondary Insurance

Insurance Carrier Name:Group Number:ID Number:Policyholder’s Name:Policyholder’s DOB:Policyholder’s SS#:Relationship to Insured:Insurance Address:City, State, Zip:Phone Number:Fax Number:

I heard about Sinai Bariatric through: Family/Friend Insurance Internet

Magazine Newspaper Primary Care Physician

TV Other:



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NAME: _________________________________

Medical History (all that apply):

Anxiety Fibromyalgia Reflux Disease (Heartburn

or severe indigestion)

Arthritis Heart Attack Seizures

Asthma High blood

pressure (Hypertension)

Sleep Apnea Diagnosed Observed

Bronchitis

Hypercholesterolemia (High cholesterol)

Snore

Cancer

Hypertriglyceridemia (High triglycerides)

Stress Incontinence

Cardiac Surgery Hyperthyroidism Stroke Chest Pains Hypothyroidism Varicose Veins CHF Leg Ulcers Other : Depression Lower back pain Diabetes Type I

(Insulin dependent)

Migraines/Headache Diabetes Type II

(Non-insulin dependent) Peripheral Edema

(Swelling of the



The doctor will complete this section.CC: Morbid obesityHP: This is a _______ year old male/ female G __ P __ A__ morbid obese patient interested in bariatric surgery. His/Her current weight is _____ lbs. and a height of ____ resulting in a BMI of _____. His/Her ideal weight should be _____ lbs. for a BMI of 25. His/Her excess weight has been calculated to be _____ lbs. He/She has been unable to control or reduce their weight by medical management.

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legs) DVT (Leg Blood Clots) Pneumonia

NAME: _________________________________

Surgical History (all that apply): Check if no surgical history

Hospital Admissions: Check never been admitted to the hospital



Surgery Date Comment C section Number:

Gall Bladder Open Laparoscopic

Hernia Hiatal Inguinal Incisional Umbilical

Hysterectomy Abdominal Vaginal

Obesity – previous Band Gastric By-

pass Sleeve

Orthopedic Type: Tubal Ligation Other (list surgeries and year) :

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NAME: ________________________________Health History (all that apply):



Hospital Date Reason

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HEAD AND NECK N/A

Change in vision Ringing in ears Nosebleeds

Double vision Dizziness Hoarseness

Deafness Sinusitis Other

CARDIOVASCULAR N/A

Palpitation Leg pain w/ walking High cholesterol

Chest Pain Heart disease or Attack High Blood Pressure

Leg Swelling Other (please list):

RESPIRATORY N/A

Cough Asthma/Bronchitis Shortness of Breath

Wheezing Sleep ApneaDiagnosed Observed

Other (please list):

GASTROINTESTINAL N/A

History of Ulcers Abdominal pain Changes in bowel habits

Difficulty w/ swallowing Vomiting History of blood transfusion

Nausea Bloody Stools History of polypsHeartburn/Reflux Jaundice Other (please list)

URINARY N/A

Difficulty urinating Stress incontinence Frequent UTI/Kidney Infections

Urinating at night Kidney stones Other (please List)

NEUROLOGIC N/A

Numbness or tingling Weakness Other (please list)Seizures Previous Stroke

ORTHOPEDICS N/A

Back pain Arthritis Difficulty walking

History of fractures Body Aches Other (please list)

PSYCHIATRIC N/A

Panic attacks Sleeping difficulties Bipolar disorder

Chronic depression Attempted suicide Other (please list)

ENDOCRINE N/A

Thyroid Problems Hair Loss Other (please list)

Menstrual Problem DiabetesInsulin Non-Insulin

HEALTH SCREENING N/A Last Mammogram Last Pap Smear or

Prostate examEGD (date)________ Colonoscopy (date)________

HEMATOLOGY N/A

Anemia Enlarged lymph nodes Other (please list)

Bleeding History of cancer

IMMUUNOLOGIC N/A

HIV Hepatitis B or C Other (please list)

Other (please list)

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NAME: _________________________________Drug Allergies: Check if no allergies

Medication Allergies Type of reaction

Current medication (prescription and non-prescription): Check if no medications

Medication Strength Frequency Purpose

Started(Initials /Date)

Stopped (Initials /Date)



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Social History: NAME: _________________________________

List the diets/programs have you have tried within the last 5 years:Diet or Weight Loss

MedicationYear Length in Months Number of Pounds Lost

What age were you considered obese?What was your lowest adult weight?What is your desired weight?

Check if you have used the following medications to lose weight: Phentermine Phen-Fen

Orlistat (Xenical) Meridia

B-12 shots Other



Marital Status:

Single Married Divorced Separated Widowed

Ethnic Origin: Black/African American Hispanic White/Caucasian Asian/Oriental Other:

Education: 9 to 11 years High School

Graduate/GED Vocational/Technical Some College College Graduate Post Graduate Degree

Number of Children:

None 1 2 3 4 5 or more

Religion: Catholic Jehovah Witness Jewish Prostestant Other (List):

__________________

Do you use tobacco products? If yes, what kind:

Cigarettes Cigars Chewing tobacco

Yes Never Smoked Former Smoker If yes, how much:

1/2 pack or less per day Between 1 – 1.5 packs per

day Between 1.5 – 2 packs per

day 2 packs or more per day

Do you drink alcohol? Yes If yes, how much:

Less than 2 per day Between 2 – 5 per day Between 6 – 10 per day More than 11 per day

No If yes, how often:

Daily Weekly Monthly

Occasionally

Have you ever used illegal drugs? Yes No If yes, what kind:

Marijuana Cocaine Heroin Amphetamines

If you still use drugs, how often:

Daily Weekly Monthly Occasionally

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Check the eating behaviors which have contributed to weight gain: Skipped meals Frequent sweets Vomiting after large meals Large portions High carbohydrate diet Frequent snacking Fatty foods Binge eating Fast foods Emotional eating Laxative use Other:

Family History: NAME: _________________________________



Weight

Health ProblemsMother Diabetes

Heart Disease High BP High

Cholesterol

Sleep Apnea

Joint Disease

Stroke

Obesity Reflux

Disease Lupus Other:

Father Diabetes Heart Disease High BP High

Cholesterol

Sleep Apnea

Joint Disease

Stroke

Obesity Reflux

Disease Lupus Other:Maternal

Grandmother(Mother’s Mother)

History of Cancer/Type

____________

MaternalGrandfather(Mother’s Father)


____________

PaternalGrandmother(Father’s Mother)


____________

PaternalGrandfather(Father’s Father)


_____________

Sibling Brother Sister

Diabetes Heart Disease High BP High

Cholesterol

Sleep Apnea

Joint Disease

Stroke

Obesity Reflux


Rheumatoid Arthritis



Cholesterol

Sleep Apnea

Joint Disease

Stroke

Obesity Reflux





Cholesterol

Sleep Apnea

Joint Disease

Stroke

Obesity Reflux





Cholesterol

Sleep Apnea

Joint Disease

Stroke

Obesity Reflux



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Additional Information HMO’S, POINT OF SERVICE, AND MANAGED CARE PLANS:

If your insurance company is an HMO, point of service, or managed care plan, you must obtain a written out-of-network referral before your consult with the surgeon. You must follow the rules of your insurance company in order to obtain the highest level of benefits. Your primary care physician’s office will need to contact the insurance company for a referral. You may make an appointment with the surgeon; however, the referral must be received or brought with you to the appointment.

SELF PAY PATIENTS: If your insurance does not cover weight loss surgery and you wish to proceed as a cash patient, please contact the office for fees and scheduling information.

DIETITIAN FEE :A dietitian fee is required at your initial appointment. This fee is non-refundable.

PAIN MEDICINE : Do not take any “pain medication/anti-inflammatories” three weeks prior to surgery without consulting with your surgeon (see list on page 2). Most pain medicines increase the chance of bleeding. This may result in cancellation of your procedure.

IMPORTANT NOTICES

We only accept cash or credit card as acceptable form of payment.

We require 24 hour notice if you are unable to keep your scheduled appointment. A fee of $25 will be

billed to you for each missed appointment.



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Nutrition & Eating Habits Questionnaire

NAME: _________________________________

Complete the following questions. Please fill out as honestly and as with much detail as possible. Turn this in with your application.

Please list any food or drink with calories you have consumed in the past 24 hours:Meal Time Place What & how much

Breakfast

Snack

Lunch

Snack

Dinner

Snack

1. What kinds of beverages do you drink and how much how often?How often per day/week How much (ounces)

Regular Coffee/TeaDecaf coffee/TeaRegular SodaDiet SodaJuiceOther drinks with sugar

2. How many meals do you eat away from home on weekdays? Breakfast ___________ Lunch __________ Dinner ___________

3. How many meals do you eat away from home on the weekends? Breakfast ___________ Lunch __________ Dinner ___________



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4. Do you currently take vitamins or minerals? Yes No If yes, list the names and amounts you take:_____________________________________________________

NAME: _________________________________5. Do you have any food allergies? Yes No If yes, which foods and type of allergic reaction? ___________________________________________________________

6. Do you have any food intolerance? Yes No If yes, please circle which food causes intolerance? Lactose Spicy Acidic Caffeine MSG Sugar substitutes Other: ___________________________________________________7. Do you use sugar substitutes? Yes No If yes, which one? ________________

8. What do you do for a living and how many hours do you worked per week? ___________9. Do you travel with your career? Yes No If yes, how often? __________________

10. Marital status: Single Married Divorce Number of children ____________

11. Who prepares the meals in your home? _____________________________________________________

12. Who does the grocery shopping? ____________________________________________

13. Are there any religious, ethnic, or cultural factors affecting food choices? Yes No If yes, please elaborate ____________________________________________________

14. Are the meals cooked in the home low fat? All the time Sometimes Never

15. Do you eat fried, stir fried, or sautéed foods cooked at home? Yes No If yes, how often and which type? ___________________________________________

16. What kind of fats do you use for frying and sautéing at home? Butter Margarine Olive Oil PAM type spray Shortening or Lard Other: _______________

17. What kind of spreads do you use for bread? Reduced calorie margarine Margarine Butter Other: _______________



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18. What is the food/drink that you will have the hardest time giving up? ________________________________________________________________________________________

19. Describe frequent cravings: _______________________________________________________________________________________________________________________________________________________________________________________________

20. Do you wake up in the middle of the night hungry? Yes No If yes, how often? __

__________________________________________________________________________21. Do you remember what you eat? Always Sometimes Never

NAME: _________________________________22. List the restaurants where you often eat:

_____________________________________________________________________________________________________________________________________________________________________________________

23. Do you eat when you are? Bored Happy Sad Stressed

24. Do you ever binge on food until you are uncomfortable or ill? Yes NoIf yes, how often? ________________________________________________________

25. Do you drink alcohol? Yes No If yes, how many at a time and how often? ________

26. Do you smoke? Yes No If yes, how many cigarettes a day? ________________

27. Do you exercise now? Yes No If yes, what exercise do you do and how often do you exercise? __________________________________________________________________________________________________________________________________

28. Is there any reason why you cannot exercise or should not exercise? _______________________________________________________________________________________



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29. Has your weight changed in the past year? Yes No If so, how much have you gained or lost? Gained _____ pounds Lost _____ pounds

30. What do you think is a realistic weight for you? _______________________________

List the diets/programs have

you have tried within the last 5

years:Diet or Weight Loss

Medication

Year Length in Months Number of Pounds Lost

31. Have you had a previous weight loss surgery? Yes No If yes, list the date the surgery was performed, which procedure was done, and where the procedure was performed. ____________________________________________________________

NAME: _________________________________32. What kind of education were you given with the previous weight loss surgery?

_____________________________________________________________________________________________________________________________________________________________________________________________________________________

33. Do you use any meal replacement products (liquids, bars, protein shakes)? Yes No If yes, which ones and how often? __________________________________________________________________________________________________________________

34. Do you use any other dietary supplements on a regular basis? Yes No Black Kohash DHEA Fiber powders/tablets Fish or Flaxseed oil Garlic pills Glucosamine Chondrontin Herbs Premarin Amounts: _____________________________________________________________________________________________________________________________________________________________________________________________________________



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35. Have you had any history with eating disorders? Yes No Such as binge eating and then vomiting or not eating or eating very little for long periods of time. If so, please be specific on age/type of eating disorder/year disorder occurred/ duration of disorder and circumstances that were contributing to the issue. If you were professionally treated, how long ago was the treatment and did you receive clearance from your doctor? __________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

36. Do you have any special needs for education material due to: Reading problems Deafness

Poor eyesight Other: _________________________

Charlotte Dunlap RD, LDN410-701-4881 (Office) 410-601-9014(Fax)

[email protected]



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Dear Patient: - LifeBridge Health | Mainlifebridgehealth.org › Uploads › Public › Documents...

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