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‘Getting Started’This packet contains the following important information to assist you in getting started:
▶ Free Surgical Weight Loss Seminar
▶ ‘Getting Started’ What to Do Next
▶ Bariatric Surgery Information Sheet
▶ Surgical Weight Loss Support Group
▶ Behavior Modification Techniques
▶ Pre-Surgery Diet Practice Tips
▶ Bariatric Surgery Comparison
▶ Co-Morbidity Reduction After Bariatric Surgery
▶ BMI vs Mortality
▶ Long-Term Survival
▶ Insurance Benefit Worksheet*
▶ Patient Health History Form*
▶ Diet History Form*
▶ Seminar Questionnaire*
* Please fill out and return
110 LBS. DOWN
Frank: 110+ LBS. DOWNNewFit Patient
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
Free Surgical Weight-Loss SeminarWe’re glad you are here!
▶ Free NewFit Bariatric Weight-Loss Seminar
▶ Free NewFit Bariatric Weight-Loss Support Group
▶ No Administrative Fees
In addition, our NewFit Bariatric Program Members will be offered Health First Pro-Health & Fitness Center:
▶ Waived enrollment fee (up to $100 value),
plus $35 per month reduced membership
fee prior to surgery
▶ FREE 3-month membership post-surgery
upon receipt of medical clearance from
the Program Member’s NewFit physician
Please remember to fill out the Insurance Benefit Worksheet and the Seminar Questionnaire and turn in at the end of the seminar, and receive your complimentary Health First Pro-Health & Fitness Center 1-day pass. Thank you!
Carol: 87+ LBS. DOWNNewFit Patient
87 LBS. DOWN
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
‘Getting Started’ What to Do Next!Check off as you complete each task!
Attend NewFit surgical weight loss seminar. Be sure to fill out the insurance benefit worksheet in your folder and turn it in.
The NewFit office will call to discuss your insurance benefits or self-pay options.
Attend office consultation.
Complete 3 to 6-month physician-supervised weight loss visits with your surgeon IF required by your insurance company.
Pre-op nutrition evaluation. Date and time to be scheduled at initial appointment.
Study your “Nutritional Guidelines” book, which explains the pre-/post-op diet requirements and what eating will be like after surgery. (You will receive this at your nutrition appointment.)
Exercise physology evaluation. Date and time to be scheduled at initial appointment.
Pre-op psychological evaluation. Refer to list provided. (To be scheduled by patient.)
Attend Pre-op education class to be scheduled at initial appointment.
Once we have all required documentation we will obtain insurance authorization from your insurance company or arrange your payment if you are self-funding your surgery.
Attend pre-op appt. (This is scheduled after your authorization is approved.)
Attend Support Group meetings a minimum of one time before surgery.
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
▶ Psychology Associates of Brevard Dr. Robert Shapiro, Ph.D. & Kelly Jo Kaye, LMHC
Insurances accepted: Aetna, BCBS, Cigna, HFHP, Magellan, Medicare, Tricare, & UHC
6767 N Wickham Road, Suite 306, Melbourne, FL 32940 321.751.1925
▶ Dr. Wanda Bethea, Ph.D. Insurances accepted: Cigna, HFHP, Magellan & Tricare
405 E. Strawbridge Avenue, Melbourne, FL 32901 321.724.6177
▶ Dr. William Eyring, Ph.D. Merritt Island location: Tuesday, Wednesday, & Thursday
Insurances accepted: Aetna, BCBS, Cigna, HFHP, Magellan, Medicare & Tricare
1395 N. Courtenay Parkway, Merritt Island, FL 32953 321.459.1003
▶ Dr. Robert Lehton, Ph.D. Insurances accepted: BCBS, Aetna, Cigna, HFHP, Magellan, Medicare & Tricare
3000 N Atlantic Ave, #102, Cocoa Beach, FL 32931 321.784.5367
▶ Dr. Stephen D. Cotton, MSW, Ph.D. Insurances accepted: BCBS, HFHP, Magellan, Medicare & Tricare
2123 Franklin Drive NE, Palm Bay, FL 32905 321.724.1614
Pre-Surgery Nutrition/ Dietician EvaluationEvery patient needs a pre-op nutrition evaluation/education sessions with our dietician. Our office will arrange this appointment after your initial office consultation. Insurance may not cover the cost of this appointment. If it is not a covered benefit, you will be responsible for payment at a self-pay rate PRIOR to the
date of service.
Exercise Physiology EvaluationNewFit will provide our members the opportunity to meet with an Exercise Trainer for evaluation and goal setting for activity enhancement. Our office will arrange this appointment after your initial office consultation.
Psychological EvaluationIt is your responsibility to make arrangements for a psychiatric/psychological evaluation.
Below are some recommendations. A referral cannot be sent for you. We do recommend that you come in for your office consultation FIRST BEFORE scheduling/attending your psych evaluation.
Bariatric Pre-Surgery Information Sheet
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
Surgical Weight Loss Support GroupStart today!
FocusFor patients who have had bariatric surgery or are considering bariatric surgery (Lap-Band, Sleeve Gastrectomy, Gastric Bypass). Feel free to bring a family member or friend with you.
Support Group Leaders ▶ Michele Pineault, RN, Bariatric Coordinator
Office: 321.434.9476 Mobile: 321.412.8252 Email: [email protected]
▶ Jessica Miller, LD RD Office: 321.434.9408 Email: [email protected]
Location/Date/Time ▶ Viera Hospital
(Pro-Health & Fitness Center Classroom)
8705 N. Wickham Road, Viera, FL 32940 Meets 2nd Monday of every month at 6 pm
▶ Palm Bay Hospital (Cafeteria Private Dining Room)
1421 Malabar Road NE, Palm Bay, FL 32907 Meets 4th Monday of every month at 6 pm
625 LBS down & counting
–Real Patients
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
Behavior Modification TechniquesFor before and after surgery!
▶ Do not eat in front of TV.
▶ Do not read while eating.
▶ Pre-portion your food and put the box or package away.
▶ Keep tempting foods out of the house.
▶ Do not go to the grocery store hungry.
▶ Make a shopping list.
▶ Use smaller plates, bowls, and utensils.
▶ Keep healthy foods available.
▶ Focus on activities other than eating.
▶ Brush your teeth after every meal if feeling the desire to eat.
▶ Do not stand or eat at the food table at parties.
▶ Offer to bring a healthy food item to parties.
▶ Park your car far away from your destination.
▶ Get up to change the TV channel instead of using the remote control.
▶ Take the stairs instead of the elevator.
▶ Keep a food and exercise diary/journal.
▶ Begin some form of exercise or activity.
▶ If you feel hungry after eating or between meals, chew sugarless gum.
180 LBS. DOWN
Nancy: 180+ LBS. DOWNNewFit Patient
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
Pre-Surgery Diet Practice TipsBefore surgery!
▶ Stop using sugar. Use sugar substitutes such as Sweet and Low, Equal or Splenda.
▶ Choose low-fat foods and avoid fried foods.
▶ Stop drinking sugar-sweetened beverages such as regular soda, sweet tea, and sweetened Kool-Aid.
▶ Start weaning off of caffeine and carbonated beverages.
▶ Start cutting back on fast food and eating out. Begin making healthy meal choices when
eating out and at home.
▶ Eat three meals a day. Do not skip breakfast.
▶ Start decreasing portion sizes —buy a food scale and pre-measure portions.
▶ Eat more fruits and vegetables.
▶ Practice drinking water and other calorie-free fluids between meals and not with meals.
▶ Drink 64 ounces of water a day.
▶ Practice sipping liquids. No straws.
▶ Avoid alcohol.
▶ Review the information on the pre- & post-op diet in the Nutritional Guideline packet.
▶ Practice chewing foods thoroughly 20 to 40 times or to a paste consistency.
▶ Purchase your protein drinks or supplements before surgery.
▶ Purchase your vitamin and mineral supplements before surgery.
▶ Begin planning a schedule for mealtime, fluids, vitamin, and minerals.
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
Bariatric Surgery ComparisonSurgical Snapshot:
GASTRIC BAND GASTRIC SLEEVE GASTRIC BYPASS
Surgical Difficulty Easiest Easy Moderate
Operation Time 1 Hour 1-2 Hours 2-3 Hours
Operative Risk Safest Safe Moderate
Performed* Laparoscopically Robotic/Laparoscopic Robotic/Laparoscopic
Hospital Stay 0-1 Days 1-2 Days 2 Days
Days to Return to Work** 5-7 Days 7-10 Days 7-10 Days
Initial Weight Loss 1-2 pounds/week 2-4 pounds/week 5+ pounds/week
Total Weight Loss 50% 60-70% 70-80%
Effectiveness High Higher Highest
Maintenance Moderate Lowest Low
* Refers to the method most-commonly used by NewFit for a particular procedure. We perform virtually all gastric bypass and gastric sleeve procedures robotically, depending on individual patient variables and additional criteria.
** Based on average return to work with lifting restrictions or light duty for six weeks after surgery.
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Quality of life improved in95% of patients
Mortality 89% reduction in5-year mortality
Co-Morbidity Reduction After Bariatric Surgery
Migraines57% resolved
Depression55% resolved
Obstructivesleep apnea74-98% resolved
Asthma82% improvedor resolved
Cardiovascular disease82% risk reduction
Hypertension52-92% resolved
GERD72-98% resolved
Stress urinaryincontinence44-88% resolved
Degenerativejoint disease41-76% resolved
Pseudotumorcerebri
96% resolved
Non-alcoholic fattyliver disease
90% resolved steatosis37% resolution of
inflammation20% resolution
of fibrosis
Dyslipdemiahypercholesterolemia
63% resolved
Metabolicsyndrome
80% resolved
Type IIdiabetes mellitus
83% resolved
Venous stasis disease95% resolved
Gout72% resolved
Polycystic ovarian syndrome
79% resolution of hirsutiam100% resolution of mental dysfunction
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
BMI vs Mortality
Rel
ativ
e M
ort
alit
y R
ate
BMI (kg/m2)
Low Risk
Medium Risk
High Risk
0
50
100
150
200
250
300
350
16 19 22 25 28 31 34 37 40 45
MIND
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EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
Long-Term Survival
0
1
2
3
4
5
6
7
8
0.68%
6.17%
No Surgery
% M
ort
alit
y
Bariatric Surgery
Risk of death decreases
89% reduction in risk of death over 5 years for those
who pursued surgery.
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
Notes
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
WT B M I4’8” 4’9” 4’10” 4’11” 5’0” 5’1” 5’2” 5’3” 5’4” 5’5” 5’6” 5’7” 5’8” 5’9” 5’10” 5’11” 6’0” 6’1” 6’2” 6’3” 6’4” 6’5” 6’6”
200 45 43 42 41 39 38 37 36 34 33 32 31 30 30 29 28 27 26 26 25 24 24 23205 46 44 43 42 40 39 38 36 35 34 33 32 31 30 29 29 28 27 26 26 25 24 24210 47 46 44 43 41 40 39 37 36 35 34 33 32 31 30 29 29 28 27 26 26 25 24215 48 47 45 44 42 41 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26 26 25220 49 48 46 45 43 42 40 39 38 37 36 35 34 33 32 31 30 29 28 28 27 26 25225 51 49 47 46 44 43 41 40 39 38 36 35 34 33 32 31 31 30 29 28 27 27 26230 52 50 48 47 45 44 42 41 40 38 37 36 35 34 33 32 31 30 30 29 28 27 27235 53 51 49 48 46 45 43 42 40 39 38 37 36 35 34 33 32 31 30 29 29 28 27240 54 52 50 49 47 45 44 43 41 40 39 38 37 36 35 34 33 32 31 30 29 29 28245 55 53 51 50 48 46 45 44 42 41 40 38 37 36 35 34 33 32 32 31 30 29 28250 56 54 52 51 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 31 31 30 29255 57 55 53 52 50 48 47 45 44 43 41 40 39 38 37 36 35 34 33 32 31 30 30260 58 56 54 53 51 49 48 46 45 43 42 41 40 39 37 36 35 34 33 33 32 31 30265 60 58 56 54 52 50 49 47 46 44 43 42 40 39 38 37 36 35 34 33 32 32 31270 61 59 57 55 53 51 50 48 46 45 44 42 41 40 39 38 37 36 35 34 33 32 31275 62 60 58 56 54 52 50 49 47 46 45 43 42 41 40 38 37 36 35 34 34 33 32280 63 61 59 57 55 53 51 50 48 47 45 44 43 41 40 39 38 37 36 35 34 33 32285 64 62 60 58 56 54 52 51 49 48 46 45 43 42 41 40 39 38 37 36 35 34 33290 65 63 61 59 57 55 53 52 50 48 47 46 44 43 42 41 39 38 37 36 35 34 34295 66 64 62 60 58 56 54 52 51 49 48 46 45 44 42 41 40 39 38 37 36 35 34300 67 65 63 61 59 57 55 53 52 50 49 47 46 44 43 42 41 39 39 38 37 36 35305 69 66 64 62 60 58 56 54 52 51 49 48 47 45 44 43 41 40 39 38 37 36 35310 70 67 65 63 61 59 57 55 53 52 50 49 47 46 45 43 42 41 40 39 38 37 36315 71 68 66 64 62 60 58 56 54 53 51 49 48 47 45 44 43 42 41 39 38 37 37320 72 69 67 65 63 61 59 57 55 53 52 50 49 47 46 45 44 42 41 40 39 38 37325 73 71 68 66 64 62 60 58 56 54 53 51 50 48 47 45 44 43 42 41 40 39 38330 74 72 69 67 65 63 61 59 57 55 53 52 50 49 47 46 45 44 42 41 40 39 38335 75 73 70 68 66 63 61 60 58 56 54 53 51 50 48 47 46 44 43 42 41 40 39340 76 74 71 69 67 64 62 60 59 57 55 53 52 50 49 48 46 45 44 43 41 40 39345 78 75 72 70 68 65 63 61 59 58 56 54 53 51 50 48 47 46 44 43 42 41 40350 79 76 72 71 69 66 64 62 60 58 57 55 53 52 50 49 48 46 45 44 43 42 41355 80 77 74 72 70 67 65 63 61 59 57 56 54 53 51 50 48 47 46 44 43 42 41360 81 78 75 73 71 68 66 64 62 60 58 57 55 53 52 50 49 48 46 45 44 43 42365 82 79 76 74 71 69 67 65 63 61 59 57 56 54 53 51 50 48 47 46 45 43 42370 83 80 78 75 72 70 68 66 64 62 60 58 56 55 53 52 50 49 48 46 45 44 43375 84 81 79 76 73 71 69 67 65 63 61 59 57 56 54 52 51 50 48 47 46 45 43380 85 82 80 77 74 72 70 67 65 63 62 60 58 56 55 53 52 50 49 48 46 45 44385 87 84 81 78 75 73 71 68 66 64 62 60 59 57 55 54 52 51 50 49 47 46 45390 88 85 82 79 76 74 72 69 67 65 63 61 59 58 56 55 53 52 50 49 48 46 45395 89 86 83 80 77 75 72 70 68 66 64 62 60 58 57 55 54 52 51 50 48 47 46400 90 87 84 81 78 76 73 71 69 67 65 63 61 59 58 56 54 53 51 50 49 48 46405 91 88 85 82 79 77 74 72 70 68 66 64 62 60 58 57 55 54 52 51 49 48 47410 92 89 86 83 80 78 75 73 71 68 66 64 63 61 59 57 56 54 53 51 50 49 48415 93 90 87 84 81 79 76 74 71 69 67 67 63 61 60 58 56 55 53 52 51 49 48420 94 91 88 85 82 80 77 75 72 70 68 66 64 62 60 59 57 56 54 53 51 50 49425 96 92 89 86 83 81 78 75 73 71 69 67 65 63 61 59 58 56 55 53 52 51 49430 97 93 90 87 84 81 79 76 74 72 70 68 66 64 62 60 58 57 55 54 52 51 50435 98 94 91 88 85 82 80 77 75 73 70 68 66 64 63 61 59 58 56 55 53 52 50440 99 95 92 89 86 83 81 78 76 73 71 69 67 65 63 62 60 58 57 55 54 52 51445 100 97 93 90 87 84 82 79 77 74 72 70 68 66 64 62 61 59 57 56 54 53 52450 101 98 94 92 88 85 83 80 77 75 73 71 69 67 65 63 61 60 58 56 55 54 52455 102 99 95 92 89 86 83 81 78 76 74 71 69 67 65 64 62 60 59 57 56 54 53460 103 100 96 93 90 87 84 82 79 77 74 72 70 68 66 64 63 61 59 58 56 55 53465 105 101 97 94 91 88 85 83 80 78 75 73 71 69 67 65 63 62 60 58 57 55 54470 106 102 98 95 92 89 86 83 81 78 76 74 72 70 68 66 64 62 61 59 57 56 54475 107 103 100 96 93 90 87 84 82 79 77 75 72 70 68 66 65 63 61 60 58 56 55480 108 104 101 97 94 91 88 85 83 80 78 75 73 71 69 67 65 64 62 60 59 57 56485 109 105 102 98 95 92 89 86 83 81 78 76 74 72 70 68 66 64 62 61 59 58 56490 110 106 103 99 96 93 90 87 84 82 79 77 75 73 71 69 67 65 63 61 60 58 57495 111 107 104 100 97 94 91 88 85 83 80 78 75 73 71 69 67 65 64 62 60 59 59
What is Your BMI?
MIND
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& BEYOND
Patient Information Patient Name ______________________________________________________________________________________________ M F
Date of Birth___________________________________________ Social Security Number__________________________________________
Address _______________________________________________________________________________________________________________
City_______________________________________________________________State_____________ Zip _______________________________
Phone ______________________________Cell __________________________ Email Address_______________________________________
Height___________________ Weight ___________________ BMI _____________________
Check the procedure most interested in: Gastric Band Gastric Sleeve Gastric Bypass Revision/Different (I’ve had Bariatric Surgery)
Please let us know about your interest in proceeding (check one below): I’m ready now in 1-2 months in 3-6 months >6 months Unsure Never
Please check all that apply to you: Morbid Obesity Asthma High Cholesterol
Obstructive Sleep Apnea Depression Osteoarthritis
Type II Diabetes GERD/Heartburn Hypertension/High BP
Pseudo Tumor Cerebri Urinary Stress Incontinence Swelling of the Legs (Edema)
Primary InsuranceInsurance __________________________________________________________ Policy #/Subscriber ID _______________________________
Group ___________________________Phone _____________________________ Policy Holder’s DOB _______________________________
Policy Holder’s Name ______________________________________________Relationship to Patient _______________________________
Employer’s Name_______________________________________________________________________________________________________
Secondary InsuranceInsurance __________________________________________________________ Policy #/Subscriber ID _______________________________
Group ___________________________Phone _____________________________ Policy Holder’s DOB _______________________________
Policy Holder’s Name ______________________________________________Relationship to Patient _______________________________
Employer’s Name_______________________________________________________________________________________________________
Primary Care PhysicianPrimary Care Physician’s Name_______________________________________________________Phone______________________________
Address _______________________________________________________________________________________________________________
City_______________________________________________________________State_____________ Zip _______________________________
Insurance VerificationI, _____________________________________________________________________ , authorize the verification of insurance benefits to
Dr. Nathan Allison Dr. Kenneth Tieu
Signed____________________________________________________________ Date _______________________
Insurance Benefit WorksheetSeminar Date______________________________________
(Please fill out as completely as possible. Thank you!)
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
MIND
DIET
EXERCISE
& BEYOND
Patient Health History Form(page 1 of 2)
Patient Name___________________________________________________________________________
Date of Birth___________________________________________ Date____________________________
Pharmacy/Address/Phone #______________________________________________________________________________________________
Active Medical Problems:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Significant Past Medical Problems:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Surgery (List all surgeries you’ve had—procedure & date):_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Family History: Circle & state relation to you: Social History:Breast Cancer ________________________Hypertension _________________________Lung Cancer _________________________Diabetes _____________________________Colon Cancer _________________________Heart Disease ________________________
Thyroid Cancer _______________________Stroke _______________________________Lymphoma/Leukemia __________________Heart Prostate Cancer _________________Kidney Disease ________________________Heart Attack __________________________
Do you smoke? Y N If yes, how much? How long? _____Do you drink alcohol? Y NMore than 3 beers or 2 drinks/day? _____Have you ever used drugs? Y NIn the past? Y N Currently? Y N
Women Only: Have you had a hysterectomy? Y NHave your ovaries been removed? Y N If yes, RT / LT / BothHave you had a tubal ligation (tubes tied)? Y N
Previous Breast Biopsy? ____________________Date & Location of last mammogram:
__________________________________________________________
Medications: Are you currently taking any medications? Y N Coumadin/Warfarin Y N Plavix Y N Aspirin Y NPain Medications ____________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies: Please CirclePenicillin / Sulfa / MycinsCipro / Levaquin / Other ___________________________________Latex X-Ray DyeTetanus Toxoid / FoodsMorphine / Codeine / DemerolPercocet / Lortab / OxycodoneOther ____________________________________________________
Be sure to include any vitamins and over-the-counter medicines.Medication Name:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________
Strength / Mg:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Frequency / Dose:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Attach a separate page if needed, list all medications you take.
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
MIND
DIET
EXERCISE
& BEYOND
Patient Health History Form(page 2 of 2)
Patient Name_________________________________________________________________
Date of Birth______________________________________ Date_______________________
System Review (Please circle any of the following you are currently experiencing or have in the past):
Constitutional: FeverChillsMalaiseNight SweatsWeight Gain
Eyes:Blurred VisionDouble VisionCorrective GlassesSurgeryHoarsenessNose Bleeds
Ears / Nose / Throat:Hearing LossSore ThroatDifficulty SwallowingHoarsenessNose Bleeds
Respiratory / Lungs:AsthmaCOPDEmphysemaSleep ApneaChronic or Frequent CoughCPAP MachineShortness of Breath with Mild ExertionWheezingCoughing up BloodLung MassTuberculosisPulmonologist’s Name: _____________________
Cardiovascular / Heart:Heart AttackChest PainRheumatic FeverCHFIrregular Heart BeatHigh Blood PressurePacemakerAngioplastyCardiac StentsDefibrilatorCardiac CathDate: __________________Name of Cardiologist: ______________________
Genitourinary / Kidney / Bladder:Pain with UrinatingKidney StonesUrinary Frequency (# of times / night ___)Prostate DiseaseCancerNephrologist’s Name: ______________________
Hematologic / Lymphatic:AnemiaLeukemiaLymphomaLymph Node EnlargementSickle CellLymph Node BiopsyBleeding GumsHematologist’s Name: ______________________
Psychiatric:DepressionAnxietyAlcohol AbuseDrug AbuseMood swings
Gastrointestinal:Abdominal PainNauseaVomitingAcid RefluxConstipationDiarrheaColitisUlcersGallstonesPancreatitisJaundiceDiverticulitisDiverticulosisColon PolypsColon CancerVomiting BloodBloody StoolsBlack StoolsHemorrhoidsLast Colonoscopy: _________________________Last EGD: _________________________________
Endocrine:DiabetesThyroid DiseaseParathyroid DiseaseAdrenal DiseaseHeat / Cold IntoleranceEndocrinologist’s Name: ____________________
Neurologic:Recurrent HeadachesMigrainesEpilepsyTiaStrokeSyncopeMemory LossNeurologist’s Name: ________________________
Musculoskeletal:FractureBack PainDisc DiseaseJoint PainSurgery: ______________________
Integumentary / Skin:Rashes / Skin Cancer / HerpesMelanoma / Burns
Breast:PainMassNipple Discharge
Vascular:Venous Stasis UlcersBypassAAAVaricose VeinsVascular StentsLeg Pain With WalkingSleeping
Other Conditions Not Listed:
________________________________________________________________________________________________________________________________________________________________
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
MIND
DIET
EXERCISE
& BEYOND
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
Weight Loss Attempts Patient Name___________________________________________________________________________
Date of Birth___________________________________________ Date____________________________
PROGRAM YEAR # OF MONTHS WEIGHT LOSS
Acupuncture, Hypnosis, Jaw Wire
Atkins
Behavior Modification
High Protein/Low Card
Injections: HCG/B-12
Jenny Craig
Medifast
Nutrisystem
Opti Source
Other Diet Centers/Programs
Overeaters Anonymous
Fen-Phen/Other Medications
Physician or Dietician Directed & Supervised
Previous Weight Loss Surgery
Self-Monitored Diet & Exercise
Slim-Fast
Weight Watchers
Other: ____________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
MIND
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& BEYOND
Seminar QuestionnaireImportant Information!Seminar Date: ____________________
Facility:___________________________________________________________
We are excited that you attended. We hope you enjoyed the presentations and found them educational. In order to serve you better, would you please take a moment and answer the following questions.
Satisfaction Scale: 1 = Not Satisfied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 = Very Satisfied
1. Overall Educational Value: 1 2 3 4 5
Comments: ______________________________________________________________________________________________________
2. Financial Information: 1 2 3 4 5
Comments: ______________________________________________________________________________________________________
3. What is the most important factor in your decision to pursue weight loss surgery? (Please check one.)
Surgeon Procedure Facility Affordability Other: ________________________________________________
4. How likely are you to move forward with surgery? Very Likely Unlikely
If likely, please check one of the options below.
Within 1-2 months Within 3-6 months > 6 months
5. How did you find out about this seminar? (Please check all that apply.)
Billboard Newspaper Magazine Email Physician Name: __________________________________________
Internet TV Radio Friend or Relative Other: ____________________________________________________
6. Have you attended other weight loss program seminars in the area? Y N
If yes, where: ____________________________________________________________________________________________________
7. Would you recommend this seminar to a family member or friend?: Y N
If not, why: ______________________________________________________________________________________________________
ADDITIONAL RECOMMENDATIONS/COMMENTS: ____________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
8. Do you have any additional questions we did not cover?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Thank you again for attending and providing us with your input.
R08
2014
Health First Medical GroupLaparoscopic and Robotic General & Bariatric Surgery
Viera Hospital Medical Plaza 8725 N. Wickham Road, Suite 302 Viera, FL 32940Phone: 321.434.9230 (Option 3) Fax: 321.434.9231 www.HFweightloss.com
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