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PATIENT PROFILE FORM

Dr. _______________________

PATIENT INFORMATION TODAY’S DATE___/___/___

Name_________________________________________________________________________ First MI Last Address_______________________________________________________________________ Street City State Zip Home Phone __________________________Cell Phone ________________________________ (WHICH PHONE NUMBER IS BEST NUMBER TO REACH YOU?) Date of Birth___/___/______ Social Security Number ______________________ ____ Male ____ Female ____ Single ____ Married ____ Widowed Employer _________________________________________Work Phone__________________ Email Address _____________________________________ SPOUSE INFORMATION Name ________________________________________________________________________ First MI Last Date of Birth___/___/___ Social Security Number ______________________ Employer______________________________________________________________________ IF PATIENT IS A MINOR Father’s Name _________________________________________________________________ First MI Last Date of Birth ___/___/___ Social Security Number ______________________ Employer _______________________________________ Work Phone ___________________ Mother’s Name _________________________________________________________________ First MI Last Employer _______________________________________ Work Phone ___________________

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CONTACT INFORMATION For emergency, list relative not in the same household _________________________________ Relationship _________________________ Phone ____________________________________ Address_______________________________________________________________________ Who may receive your health or financial information? ________________________________ How did you hear about the UF Health Weight Loss Surgery Institute? ___ Family Member ___ Friend ___ Newspaper ___ Primary Physician ___ Flyer ___ Other

INSURANCE INFORMATION PRIMARY INSURANCE Insurance Company _______________________________________ Phone_________________ Address _______________________________________________________________________ Group #____________________________ Policy # ____________________________________ Name of Policy Holder ___________________________________________________________ Relationship to you: ___Self ___ Spouse ___Child ____Other (please specify) ______________ SECONDARY INSURANCE Insurance Company _______________________________________ Phone# _______________ Address _______________________________________________________________________ Group #____________________________ Policy # ____________________________________ Name of Policy Holder ___________________________________________________________ Relationship to you: ___Self ___ Spouse ___Child ____Other (please specify) ______________

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PATIENT HISTORY QUESTIONNAIRE The information requested in this questionnaire is VERY important. To provide the best care, and to obtain your insurance approval, we must have complete answers. PLEASE be thorough.

Name_________________________________________________ Date___________________ Age________ Occupation________________________________ Circle One: Male Female Circle one of the following: Lap Banding Open Bypass Lap Bypass YOUR MEASUREMENTS WEIGHT HISTORY

Please estimate as closely as possible for all that apply.

Measurement

YOUR Measurement

Life Event

Age

Weight

Height

Birth

Actual Body Weight

Start of High School

Target Weight

Marriage

Body Frame (circle one)

BMI

Pregnancy(s)

Small

Waist

Lowest Weight in Past 5 Years

Medium

Hips

Lowest Weight in Past 5 Years

Large

Neck

Highest Weight in Past 5 Years

Were you obese as a child? YES or NO (please circle one) Number of years 100 pounds over healthy weight: ____________________________________ Approximate age when you first seriously dieted: _____________________________________ In your own words, please describe what you hope to accomplish and how you believe your life will change by losing weight: ______________________________________________________ ______________________________________________________________________________

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WEIGHT MANAGEMENT HISTORY This form is submitted to your insurance company with your letter of medical necessity. Approval or denial of your request for surgery depends on meeting the criteria put forth by your insurance company. Failure of multiple attempted dietary programs is a standard requirement. Please fill out in detail.

Doctors who are following or have followed your weight problems:

Diet programs your doctor has you trying or has had you try:

Weight Loss

Weight Regained

Length of Program

Estimated Cost

Please provide to the best of your knowledge any weight loss program you have tried over the years. This information must be completed and is vital to your surgery authorization. Do your best to provide as much information as possible.

Program

Year

Weight Loss

Weight Regained

How many times

Length of Program

Estimated Cost

Weight Watchers

TOPS

Overeaters Anonymous

Jenny Craig

NutriSystem

LA Weight Loss

Quick Weight Loss Center

Behavior Modification

Jaws Wired

Appetite Suppressant Pills

Shots

Hypnosis

Hoodia

Set for Life

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200 Plus – Dana Thornock

How to lower your fat thermostat

Herbal Life

Slim Fast

Slim for Life

Richard Simmons

Acupuncture

Fad Diets (please specify)

Self-Imposed Diet Attempts

Other (please list)

PHYSICAL EXERCISE

Program

Time Spent

Weight Loss

Weight Regained

Length of Program

Estimated Cost

Bicycling

Jogging

Walking

Swimming

Spa Memberships

Aerobic

Video Tapes

Health Rider

Home Gym Equipment

Curves

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FOOD PREFERENCES

Eating Habits: (please circle all that describe your current eating habits)

Scheduled regular meals No set schedule/grazer Meat & potatoes type

Sweets Snacks Junk food

Fast food Large/multiple portions Eat on the go

Purging Emotional eater Eat at night

Binge/compulsive eater History of bulimia History of anorexia

Do you eat while doing other things? ___________ Do you eat without thinking? ___________

Do you meal plan in advance? _________________ Do you have food cravings? ____________

How often do you eat away from home? ________ What kind? _________________________

Food Frequency Check: (please indicate how many servings a day you consume)

____ Sweets ____ Ice cream ____Sweetened beverages

____ Vegetables ____ Fruit ____ Milk

____ Cakes ____ Cookies, pie ____ Cheese/yogurt

____ Alcohol ____ Fast food ____ Meat/meat alternatives

____ Water ____ Bread/grain products ____ Snacks, chips, crackers, etc.

____ Restaurant dining ____ Caffeine drinks (hot & cold)

____ Fried/high-fat food/French fries, etc. ____ Added fats/salad dressing, butter, etc.

____ Convenience foods/frozen dinners, deli meals, pizza and take out, etc.

Comfort Foods: _________________________________________________________________

Food Allergies: _________________________________________________________________

Food Intolerances: ______________________________________________________________

Dietary Supplements: ____________________________________________________________

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WEIGHT-RELATED ILLNESSES

Have you had, or do you have any of the following illnesses or symptoms?

Heart Disease Yes No Year diagnosed ___________________ (Circle all that apply to you) M.I. (myocardial infarction) CABG (coronary artery bypass graft) Abnormal EKG Stress Test Palpitations High Cholesterol Yes No Year diagnosed ___________________ List Medications: __________________ ________________________________ High Triglycerides Yes No High Blood Pressure Yes No Year diagnosed ___________________ Average pressure _________________ List Medications: __________________ ________________________________ Dietary Restrictions: _______________ ________________________________ Diabetes Yes No Year diagnosed ___________________ Gestational: Yes No Neuropathy: Yes No Controlled with: Diet Insulin Oral Medication List Medications: __________________ ________________________________ Asthma Yes No Year diagnosed ___________________ ER Visits in the last 2 years __________ Hospitalizations in the last 2 years ____ Steroid used in the last 2 years _______ Sleep Apnea Syn. Yes No Year diagnosed ___________________ Last Sleep Study ___________________ CPAP used Yes No Morning headaches Yes No Daytime drowsiness Yes No Restless sleep Yes No Snoring Yes No

Awakenings at night Yes No

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Coughing or choking at night Yes No Shortness of breath Yes No Can walk on level ground Yes No Long: _______________________ How many stairs: __________________ Heartburn/Esophagitis Yes No Year diagnosed ____________________ Upper GI Series Yes No Endoscopy Yes No Medications ______________________ Frequency of use ___________________ UGI Endoscopy ordered ______________ Belching acid/sour on back of throat Yes No Gallbladder Yes No How diagnosed? Ultrasound exam_____ Leakage of urine w/laughing, Yes No Wear pads frequently? _______________ coughing, sneezing Low Back strain/pain/sciatica Yes No Seen by Chiropractor? _______________ Seen by Orthopedic Surgeon? _________ Seen by Family Doctor? ______________ Medications taken __________________ __________________________________ Frequency taken____________________ __________________________________ Pain in hips/knees/ankles/feet? Yes No Seen by Chiropractor? _______________ Seen by Orthopedic Surgeon? _________ Seen by Family Doctor? ______________ Medications taken __________________ __________________________________ Frequency/dose taken________________ __________________________________ Weight related injuries & trauma Yes No __________________________________ __________________________________ __________________________________ Varicose Veins Yes No Do you have swelling? ________________ Thyroid Disease Yes No Medications? Yes No Name of Medication: _________________ __________________________________ __________________________________ __________________________________ __________________________________

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SLEEP HISTORY

How many hours sleep do you get at night? ________________________________________

What is it that keeps you up at night? _____________________________________________

____________________________________________________________________________

Would you consider the equality of your sleep is: Good Fair Poor If your sleep is a major problem to you or your partner, would you be prepared to have a sleep study performed now and after you lose weight? Yes No SYMPTOMS OF SLEEP APNEA 0 = WOULD never DOZE 1 = SLIGHT chance of dozing 2 = MODERATE chance of dozing 3 = HIGH chance of dozing

SITUATION

Chance of Dozing (circle the number corresponding to the key above

Sitting and reading 0 1 2 3

Watching TV 0 1 2 3

Sitting, inactive in a public place (e.g., a theater or a public meeting)

0 1 2 3

As a passenger in a car without a break 0 1 2 3

Lying down to rest in the afternoon when circumstances permit

0

0

1

1

2

2

3

3

Sitting quietly after lunch without alcohol

In a car, while stopped for a few minutes in the traffic

0 1 2 3

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PAST MEDICAL HISTORY

Are you allergic to any medications, foods, or materials? Yes No ______Penicillin _____Sulfa _____Latex

Other________________________________________________________________

Have you taken diet pills in the last two weeks? Yes No

Are you taking birth control pills or any other Estrogen/Progesterone? Replacement? (Patients to stop taking drug one month prior to surgery) Are you taking Aspirin or Ibuprofen for joint or back pain? Yes No (Patient to stop taking drug two weeks prior to surgery) ***Consult prescribing physician if you have any questions.

MEDICATIONS

DRUG NAME DOSAGE TREATMENT FOR COST TO YOU

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Please list below all serious illnesses and hospitalizations you have experienced in adulthood: (use back of paper if more space is needed) Major Illness Date Treatment ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Major Surgery Date Open or Laparoscopic

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Please identify which of the following childhood illnesses and operations you have experienced:

Rheumatic Fever Tonsillectomy

Age_____ Year _____ Age _____Year ______

Appendectomy Heart Murmur Obesity Blood Clots

Age_____ Year _____ Bleeding disorders Asthma

Date of last Physical___________________________________________________________ (must be done within 6 months of surgery)

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Please list all the physicians whose care you are under:

Name Location Telephone

Primary Care Physician: _______________________________________________________ Internist: ___________________________________________________________________ Gynecologist: _______________________________________________________________ Orthopedist: ________________________________________________________________ Psychiatrist: ________________________________________________________________ Psychologist: _______________________________________________________________ Therapist: __________________________________________________________________ Other: _____________________________________________________________________ May we contact your Doctor’s office? _______ For female patients only: Number of pregnancies: ______________________ Age of first period _________________ Number of live births: ________________________Date of last period _________________ Miscarriages/abortions: ______________________ Obstetric complications: _______________________________________________________

FAMILY HISTORY

Relationship

Age Health (good, fair, poor)

If deceased, cause Age deceased

Father

Mother

Brothers

Sisters

Spouse

Sons

Daughters

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Do you know of any blood relative that currently has or has had: (list relationship?)

Stroke: ____________________________________________________________________ Cancer: ___________________________________________________________________ High blood pressure: _________________________________________________________ Tuberculosis: _______________________________________________________________ Diabetes: ___________________________________________________________________ Bleeding tendency: ___________________________________________________________ Heart Attack: ________________________________________________________________

PERSONAL HABITS Are you a smoker? Yes No if yes, when did you quit? _________________________ How many years did you smoke? Cigarettes _________Pipe ________Cigar ___________ Do you drink coffee? Yes No If yes, how much? ______________________________ Do you drink alcohol? Yes No If yes, how much? ______________________________

SYSTEM REVIEW Circle all symptoms which you have now or have had. Write in any additional problems. Head, Eye, Ear, Nose, & Throat: Stuffy nose, runny nose, hay fever, sinus trouble, earache, headache, blurry vision, double vision, halos around light, loss of night vision, buzzing in ears, ringing in ears, discharge from ear, loss of hearing, dizziness, vertigo, loss of balance, sore throat, lump in throat, trouble swallowing, pain with swallowing, hoarseness. Respiratory: Cough, wheezing, shortness of breath at night, use two pillows, blood in sputum, out of breath with exertion, wake up at night short of breath; wake up at night coughing or choking, asthma, emphysema, bronchitis. Cardiovascular: Palpitation, pounding of heart, skipping of heart beat, pains in chest, pains in neck, pains, in arms, squeezing of chest, heart attack, heart murmur, abnormal electrocardiogram, irregular heartbeat, high blood pressure, pain in legs, cold feet, blue toes, blue fingers, loss of pulses.

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Genitourinary: Pain with urination, trouble starting urine, trouble stopping urine, small urine stream, blood in Urine, kidney stone, bladder stones, kidney failure, nephritis, urinary tract infections, frequent urination, getting up at night to urinate, leakage of urine with coughs or sneeze. Men: Discharge from penis, loss of erection, painful erection. Women: Vaginal discharge, vaginal bleeding, pain with intercourse, irregular periods. Endocrine (Glandular): Low thyroid, hyperthyroid, goiter, Grave’s disease, thyroid nodules, x-ray to thyroid, diabetes, adrenal gland tumor, frequent flushing, frequent heavy sweating. Musculoskeletal: Pain in joints, swelling of joints, redness of skin over joints, warm joints, fluid in joints, arthritis. Neurological: Dizziness, vertigo, falling to the side, falling at night, numbness, tingling, pins and needles feeling, weakness of any muscles, twitching of muscles, weakness of grip, shakiness, tremor, fainting, convulsions, fits, loss of consciousness. Psychological: Nervousness, anxiety, depression, thoughts of suicide, suicide attempts, hospitalizations for emotional problems, psychiatric treatment, psychological counseling. Other Problems: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________