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Welcome…

This will confirm your New Patient appointment with: Dr. Brian Binetti Dr. Vadim Meytes

Your appointment is scheduled for____________ at _________

Your appointment will take place at:

Our Rhinebeck Location: Inside Northern Dutchess Hospital, 6511 Springbrook Ave, Suite 1004. Enter through the main entrance of the hospital, take the first left past the gift shop and follow the signs for HQMP General Surgery.

Our Poughkeepsie Location: 21 Reade Place, Suite 3100. Our office is on the 3rd floor.

Our Highland Location: 514 State Route 299

Before your appointment…

➢ Complete your new patient packet If you are unable to keep this appointment, we ask that you kindly give us 48 hours cancellation notice. Please call 845-871-4275. Our office is open from 8:30 am to 5:00 pm, Monday through Friday. At the time of your appointment…

➢ Please arrive 15 minutes before your scheduled appointment so that we can review your paperwork and to complete the patient registration process.

➢ Please be sure to bring:

• Insurance card(s)

• Driver’s license or other photo identification

• Your referral, if your insurance plan requires it

• Please come prepared to pay your copayment. We accept cash, checks, credit cards.

We would like to welcome you to our practice and are pleased that you have chosen us to participate in your care. Our board certified surgeons and professional office staff are dedicated to providing you with the very best care and service. We encourage you to call us with any questions you may have.

Department of General Surgery

Health Quest Medical Practice, P.C.

6511 Springbrook Avenue, Suite 1004

Rhinebeck, NY 12572

845.871.4275

healthquest.org/HQMP

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Achieving Long Term Success

Congratulations! You have taken the first step on your weight loss journey. We recommend that you begin to make small changes in the way you eat

and live immediately; even before your first visit with the surgeon. Work on one healthy habit at a time and when you are ready, add another.

These habits will be important tools to help you be successful after surgery.

1) Never eat the last bite or drink the last drop.

a. After surgery you will get full quickly and it will be important to stop when you are full.

Many of us have trained ourselves to eat every bite on the plate. Take this time to get used to

leaving a few bites on your plate or a few crackers at the bottom of the bag.

2) Choose a healthy coping mechanism from the list and practice using it.

a. Many people use food as a way to deal with stress

b. It takes repetition and intentional use of healthy coping mechanisms for them to become

effective; think of it like growing something from a seed. This coping mechanism will require

nurturing and practice for it to become fully grown.

c. You must keep this activity completely separate from snacking

3) Chew your food (32 times per bite or until liquid).

a. Hormones are released when you chew that help to make you feel “full”.

b. Try to keep your food toward the front of your mouth so that you don’t swallow it too soon.

4) Increase your fluid intake.

a. Drink at least 64oz of non-carbonated, non-caffeinated, sugar-free liquid per day.

b. You body’s signals of thirst can be easily misinterpreted for hunger. If you are drinking enough

liquid you may feel less hungry.

c. Wean yourself off carbonated beverages; you cannot have carbonation after surgery.

5) No liquids during or for 30 minutes after eating.

a. Do not eat and drink at the same time.

b. This is to allow your food to sit in your stomach so that you can feel fuller longer.

6) Get active!

a. Make exercise a part of your daily routine.

7) Give your body what it needs

a. Make healthy food choices

i. Eat protein at every meal

ii. Eat your protein first, then vegetables, then fruit, then starchy foods

iii. Choose low fat options

b. Take your vitamins

i. If your body isn’t getting the nutrients it needs it may increase your hunger signals or you

may experience low energy

Every few days re-read the list and ask yourself… “Am I still doing these?” Making changes to lifelong habits takes persistence. It’s natural to go back

to the old way of doing things when you’re not thinking about it. By making these changes now you’re preparing yourself for long term success after

surgery.

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Name___________________________________ DOB_______________

Dear Valued Patient,

Health Quest wants to make sure you know your insurance coverage for weight loss surgery. This is just the first step. This information will help us to plan out your weight loss journey. Please call your insurance company, ask them to check your plan documents for the information below:

Name of person you are speaking to: __________________________________________ (Ask them to spell it.) Date and time of phone call: ____________________________________

1. Is there a deductible on my policy? YES or NO If yes; Amount $____________

2. Is there a co-insurance on my policy? YES or NO If yes; Amount $____________

3. Is there an out of pocket maximum on my policy? YES or NO If yes; Amount $____________

4. Will I need a referral for an appointment with a specialist?

YES or NO

5. Do I have a co-payment for an appointment with a specialist?

YES or NO If yes; Amount $____________

6. Is Bariatric Surgery (or Weight Loss Surgery) covered under my plan? (Sometimes this information will be found under “Treatment for Obesity”)

YES or NO

7. Do I need to meet requirements of a medically supervised weight loss program?

YES or NO If yes; How long? ____________

8. Who can supervise my weight loss? Primary Care Provider Nutritionist Only a Bariatric Surgeon

9. Does my insurance cover nutritional counseling with a nutritionist?

YES or NO If yes; How many visits per year? ____________

10. Do I have a co-pay to see a nutritionist? YES or NO If yes; Amount $____________

If your insurance requires diet documentation; clarify what type of weight loss program is accepted.

Make notes here:

*If your insurance changes you will need to get this information again* Please bring this completed worksheet with you to your consultation. If you are unable to call your insurance

company, please call your employer to see if weight loss surgery is covered under your policy.

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Bariatric Surgery Program History Form

Name___________________________________________

Date of Birth_____________________________________

Preferred contact (e-mail or phone) _____________________________

Insurance Provider (Example: Fidelis, MVP, Blue Cross Blue Shield)____________________________________________

Please list all other physicians or health care providers who are caring for you:

Please list any medications, vitamins/minerals and/or herbal supplements you are presently taking: Medication name (including if immediate or Dosage/Frequency Reason You Use Medication extended release, ex. XR, CR, IR, etc.)

Name of Medication/ Vitamins Dose (Mg) How often do you take it?

Reason for taking

Past Medical History: (please select “yes” if you take medication for or if you have been diagnosed with the condition)

Medical Condition YES No Please list addition past medical diagnosis below

Diabetes

Prediabetes

High Blood Pressure

High Cholesterol

Sleep Apnea If yes, do you use your Mask?

GERD

Anemia

First Name, Last Name Medical Group, City Telephone FAX

Previous Bariatric Surgeon

Internist (Primary Care)

Gastroenterologist

Mental Health

Gynecologist

Cardiologist

Pulmonologist

Other

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Please list any allergies:

Allergy (Food, drug or environmental) Reaction Date of Onset

Are you allergic to Latex Yes NO If yes; what is your reaction? ________________________________________________ Past Surgical History: Please list all previous surgeries:

Date Surgery

Past Hospitalizations: Please list all previous hospitalizations:

Date Reason

Family History

Members Status Living

Deceased or

Unknown

Year of

Birth

Age Well Diabetes High Blood

Pressure

Heart Disease

Stroke Mental Illness

Cancer Unknown

Example Grandma Living 1929 89 ✓ ✓ ✓

Father

Mother

Son(s)

Daughter(s)

Brothers (s)

Sister (s)

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Family History Notes: _____________________________________________________________________________________

_______________________________________________________________________________________________________

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Social History:

Are you a smoker? No Yes Packs/day: _______ How long have you smoked?________

Have you ever been a smoker? No Yes Age started:__________ Age quit:__________

Do you drink alcohol? No Yes Drinks per occasion: _______ Occasions per month:________

Do you use recreational drugs? No Yes

If yes, what drugs do you use, how often, and how many years?

___________________________________________________________________________________________________________

Are you pregnant or a breastfeeding mother? Yes No

If Yes, please explain_____________________________________________________________________________

How do you learn best? Hearing Watching Reading Doing Other:_______________

Do you have any problems reading?No Yes

Do you have any problems communicating? No Yes

Do you need a translator or any special assistance during consultations? No Yes

If Yes, please explain_____________________________________________________________________________

Do you have any problems making decisions, remembering, or thinking clearly? No Yes

If Yes, please explain_____________________________________________________________________________

Do you have any values, beliefs or religious practices that may influence your treatment/care? No Yes

If Yes, please explain_____________________________________________________________________________

Have you ever been physically, sexually, or emotionally abused? No Yes

Would you like to receive information on abuse resources? No Yes

Weight History:

Please check the appropriate boxes and add notes as needed (please be specific). My obesity started: In childhood At puberty After a traumatic event After pregnancy

In Adulthood Other_______________________________________________________

History of Weight loss attempts including Weight Loss Programs/Diets/Medications: Medically supervised weight loss programs (Please include dates & duration of program, and maximum weight loss) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

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What diet / weight loss programs have you tried in the past? (Check all that apply)

✓ Dates & Duration of diet Maximum weight lost

Weight Watchers

Slim-Fast

Jenny Craig

Nutrisystem

Glycemic Impact Diet

South Beach Diet

Denise Austin Diet

The Zone

Whole30

21 Day fix

Other:

Most weight lost with any attempt:__________________

Program:____________________________________

Current Weight: Height: _________________ Recent weight change in past 6 months: ____________________lbs. gain/loss (circle) Lowest weight past 5 years:________________ Highest weight past 5 years:__________________ Additional notes regarding the onset of obesity: ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Taste preferences (please check all that apply):

Sweets Salty Fast food Comfort foods Other:_________________________________

Eating Habits (please check all that apply):

Binge eater Stress Boredom Loneliness Other:_________________________________

Food Preferences:

Indicate which foods you prefer. In other words, which food would most likely make you go off a diet?

Rank each food from 1 – You like very much to 4 – You don’t care for Candy Ice cream Cookies Cake/pie Pizza Potatoes French Fries Pasta Chocolate Fast foods Chips Sodas Fried Foods Steak BBQ Snack Foods Fancy coffee drinks (mochas, frappuccinos, cappuccinos, lattes) Are there any other food preferences? (re: religious or cultural) ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

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Exercise: Please describe your exercise routine. Include type of exercise, frequency and physical limitations:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Review of Systems

General: Please check any/all that apply to you:

Functional Status: Check any/all that apply to you:

Pseudotumor Cerebri: Check any/all that apply to you:

General (Continued):

Abdominal Hernia: Check any/all that apply to you:

Stress Urinary Incontinence: Check any/all that apply to you:

No trouble walking

Able to walk 200 ft with assist device (cane/crutch)

Cannot walk 200 ft with assist device (cane/crutch)

Requires wheelchair

Bedridden

No Symptoms

Headaches with dizziness, nausea, and/or pain behind eyes

Headaches with visual symptoms, and/or controlled with diuretics

MPI confirmed diagnosis of PTC

Well controlled with stronger medications

Requires narcotics, surgical intervention done or recommended

No hernia

Hernia with no symptoms, no prior operation

History of hernia with successful repair

Hernia that keeps coming back or size >15cm

Chronic evisceration through large hernia or multiple failed repairs

No Symptoms

Minimal and intermittent

Frequent but not severe

Daily occurrence, requires sanitary pad

Disabling

Failed surgery

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Abdominal Skin / Pannus

Skin

Please check any/all that apply to you:

No Symptoms Hair/Nail Changes Keloids/large scars Rosacea Rash under folds /breasts Poor Wound Healing

Blood:

Please check any/all that apply to you:

Anemia (Iron deficiency) Bleeding Disorder

Anemia (B12 deficiency) Lymphoma HIV / AIDS Blood Transfusion Low Platelets Use of Blood Thinners Swollen Lymph Nodes Easy Bruisability Superficial clot in leg No Symptoms

Endocrine / Metabolic

Gout: Check any/all that apply to you:

Diabetes: Check any/all that apply to you

Dyslipidemia: (abnormal cholesterol/triglycerides)

Check any/all that apply to you:

No Symptoms

Irritation in skin folds under belly

Belly hangs down in a way that interferes with walking

Recurrent cellulitis or ulceration

Surgical treatment

No gout present

Hyperuricemia present but no symptoms

Hyperuricemia present, on medications

Arthropathy present

Destructive joints present

Disabled, no walking

No Diabetes

Elevated fasting blood sugar

Oral medications only

Insulin only

Insulin and oral meds

Complications present

No Dyslipidemia (High Cholesterol) No treatment required

Lifestyle change Single medication

Multiple medication Poorly controlled

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Thyroid Disease:

Check any/all that apply to you:

Respiratory

Sleep Apnea-please check any/all that apply to you:

Asthma, check any/all that apply to you:

Please check any/all that apply to you:

Chronic cough

Shortness of Breath at rest Emphysema/COPD Bronchitis Pneumonia History of blood clot in the lungs No Symptoms

Psychosocial

Mental Health Impairment: Check any/all that apply to you:

Confirmed Mental Health Disorder: Check any/all that apply to you:

No history of Asthma

Occasional Mild Symptoms, not on any meds

Symptoms controlled on oral meds or inhalers

Well controlled with daily medications

Poorly controlled, requiring steroids or anticholinergics

Hospitalization in the last 2 years/history of intubation

No impairment

Mild impairment, able to perform primary tasks

Moderate impairment, able to perform most primary tasks

Moderate impairment, unable to perform most primary tasks

Severe impairment, unable to function

None Depression

Bipolar Anxiety/Panic Disorder

Personality Disorder Psychosis

No Symptoms

Hypothyroid (low thyroid)

Hyperthyroid (overactive)

Parathyroid Problems

Goiter

No history of sleep apnea

Symptoms but sleep study/test negative

Positive sleep study/test

Require appliance/CPAP at night

Have hypoxia (low oxygen) or dependent on oxygen

Have complications related to sleep apnea

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Depression: Check any/all that apply to you:

Neurologic

Please check any/all that apply to you:

Migraine Dizziness Balance disturbance Stroke Seizure or Convulsions Multiple sclerosis Weakness Restless Leg Recurrent headaches Knocked unconscious Numbness and Tingling No symptoms

Musculoskeletal Disease

Back Pain: Check any/all that apply to you:

Fibromyalgia: Check any/all that apply to you:

Musculoskeletal Disease: Check any/all that apply to you:

No Symptoms

Episodic, no treatment required

Moderate with some impairment, may require treatment

Moderate with significant impairment, treatment indicated

Severe, intensive treatment indicated

Severe, hospitalization required

No Back Pain

Intermittent symptoms

Non-narcotic treatment

Degenerative changes, narcotic treatment

Surgical treatment done or recommended

Failed surgical treatment

No fibromyalgia

Treatment with exercise

Treatment with non-narcotic medications

Treatment with narcotics

Surgical Treatment done or recommended

Disabled, surgery failed

No musculoskeletal disease

Pain with community ambulation

Non-narcotic analgesia

Pain with household ambulation

Surgical intervention required

Joint replacement done or recommended

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Please check any/all that apply to you: None

Neck Pain Lupus Shoulder Pain Scleroderma Wrist Pain Autoimmune Disease Hip Pain Muscle Pain Knee Pain Sciatica Ankle Pain Plantar fasciitis Foot Pain Carpal Tunnel Heel Pain Rheumatoid arthritis Ball of foot / Toe Pain Broken Bones

Other: ________________________________________________________________________________________

Bladder: Check any/all that apply to you:

Kidney Stones Kidney Failure / Renal Insufficiency

Blood in Urine Leaking Urine when Sneezing Prostate Problems Previous PSA test (males only) Burning on urination Trouble Starting Urinary Urgency No symptoms

Gastrointestinal

Please check any/all that apply to you:

Abdominal Pain Colitis Heartburn Crohn’s Disease Stomach Ulcers Hemorrhoids Hiatel Hernia Rectal Bleeding Incisional Hernia Black tarry stools Diarrhea Colon Polyps Blood in stool Pancreatic Disease Change in Bowel Habits Barrett’s Esophagus Constipation Difficulty Swallowing Irritable Bowel Nausea /Vomiting

No symptoms

Other: ________________________________________________________________________________________

_____________________________________________________________________________________________

GERD (Gastroesophageal Reflux Disease): Check any/all that apply to you:

Gallstones: Check any/all that apply to you:

No GERD

Variable symptoms

Require only intermittent medications

H2 blockers (pepcid, zantac) or low dose PPI (Prevacid, Prilosec, Nexium, etc)

High dose PPI

Criteria for or history of anti-reflux surgery

No Gallstones

Asymptomatic (stones present)

Intermittent symptoms

Severe symptoms, previous cholecystectomy

Immediate GB surgery prior to weight loss surgery

Previous cholecystectomy with unresolved complications

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Liver Disease: Check any/all that apply to you:

Cardiac

Hypertension: Check any/all that apply to you:

Peripheral Vascular Disease: Check any/all that apply to you:

Deep Venous Thrombosis: Check any/all that apply to you:

Heart Disease: Check any/all that apply to you:

Lower Extremity Edema: Check any/all that apply to you:

No High Blood Pressure

Borderline HTN

Positive diagnosis

Controlled with single medication

Multiple Medications #______

Poorly Controlled

No Peripheral Vascular Disease

Asymptomatic with bruit

Claudication, anti-ischemic meds

Transient ischemic attack, rest pain

Previous procedure for PVD

Stroke, loss of tissue

Venous Stasis

No Previous DVT (Blood Clots in a deep vein)

Resolved with medications

History of recurrent DVT’s

Previous PE (blood clot in the lungs)

History of recurrent PEs

Has IVC Fliter (Vena Cava Filter)

No Liver Disease

Mild hepatomegaly, normal LFT’s, cat. 1 fatty liver

Mod. hepatomegaly, altered LFT’s, cat. 2 fatty liver

Marked hepatomegaly, cat. 3 fatty liver, mild fibrosis

NASH, cirrhosis, hepatic dysfunction

Failure, need for or previous transplant

No Ischemic Heart Disease Abnormal EKG

Active ischemia CHF

Angina Previous PCI/PTCA (Stents)

Previous CABG/catheterization History of Heart Attack

No edema (swelling)

No treatment Treatment

Stasis ulcers present Disability, hospitalization

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Please check any/all that apply to you:

Pacemaker Heart Murmur / Atrial Fibrillation Rapid Heart Rate Irregular / Skipped heart beats Varicose Veins Rheumatic fever / Valve Damage / MVP None

Other: ___________________________________________________________________________________________

Constitutional: Please check any/all that apply to you:

Fevers Anemia Weight Gain

Chills Hair Loss Insomnia

Night Sweats Fatigue Appetite Change

No symptoms

Functional Status:

Routine Cancer Screenings:

Check any/all that apply to you and date:

Other: ________________________________________________________________________________________

_____________________________________________________________________________________________

Please do not write below this line

OFFICE USE ONLY

___________________________________________________________________________________________________________

Provider Signature:____________________________________________________________

Date:_______________________ Time:_______________________

Mammogram Date:______________ (Less than 1 year old for all women over the age of 45)

PSA testing Date:______________ (For all men over age 50)

Colonoscopy Date:______________ (For all patients over age 50)

Pap Smear Date:______________ (Less than 3 years old for all female patients)

PLEASE HAVE MOST RECENT RESULTS FAXED TO OUR OFFICE (845)871-4362

Independent

Partially Dependent (require some assistance with Activities of Daily Living such as

toileting and bathing)

Totally Dependent (require assistance with ALL activities)