BARIATRIC SURGERY PATIENT MEDICAL HISTORY QUESTIONNAIRE
Please complete this questionnaire as accurately as possible. It is important for us to have this information to share with your insurance provider and to determine your eligibility for bariatric surgery. Please complete the form to the best of your ability. Thank you!
Name: ______Date: ______
Address: ______
City: ______State: ______Zip: ______
Date of Birth: ______Age: ______Gender: q Male q Female
Marital Status: ______Occupation: ______
Distance from MultiCare Allenmore Hospital: ______
Do you have access to the internet at home? q Yes q No Notes: ______
1. PRIMARY CARE PHYSICIAN OR PROVIDER: (Check one) q MD q DO q ARNP q PA-C q Other
Name: ______Phone: ( )______
Address: ______
City: ______State: ______Zip: ______
Permission to contact this physician regarding you: q Yes q No
2. OTHER PHYSICIANS OR HEALTH CARE PROVIDERS INVOLVED WITH YOUR CARE:
Name: ______Specialty: ______
Address: ______
City: ______State: ______Zip: ______Phone ( )______
Permission to contact this physician regarding you: q Yes q No
Name: ______Specialty: ______
Address: ______
City: ______State: ______Zip: ______Phone ( )______
Permission to contact this physician regarding you: q Yes q No
3. WEIGHT HISTORY:
Have you had weight loss surgery before? q Yes q No If yes, go to page 3 / if no, complete all pages except page 3
______Weight at birth (if known):______At what age did you begin to get overweight? ______Weight at start of high school: ______Lowest weight in the past 5 years: ______Highest weight in the past 5 years: ______Highest weight you ever weighed in your life: ______
Patient Identification - Always Attach Patient Label PATIENT MEDICAL HISTORY Name: QUESTIONNAIRE MRN #:
CSN #: *8818132* Age / Sex: Page 1 88-1813-2 (Rev. 3/19) 4. SUPERVISED ATTEMPTS TO LOSE WEIGHT: Please list the supervised attempts to lose weight in the past 5 years (e.g., physician, dietitian, commercial programs like Weight Watchers, Jenny Craig, LA Weight Loss, etc.). Program What Year? How Many Months? Weight Lost Weight Regained
5. UNSUPERVISED ATTEMPTS TO LOSE WEIGHT: Number of times you’ve tried losing weight: q Less than 5 q 6-10 q 11-50 q 51-75 q 76-100 q over 100 Please list, the best you can, unsupervised diet attempts over the past 5 years: Program What Year? How Many Months? Weight Lost Weight Regained
In the following space, please list any attempts other than the above, any time during your lifetime, that resulted in weight successfully lost, or that lasted more than three months. Program What Year? How Many Months? Weight Lost Weight Regained
IMPORTANT: Please keep a folder at home to store as much documentation as you can to support the above history. This is not easy, but please make the effort. That information may be extremely valuable when dealing with insurance, particularly if an appeal is needed. 6. THE MOST WEIGHT YOU HAVE LOST DURING ANY DIET PROGRAM? ______REGAINED? ______
7. WEIGHT LOSS MEDICATIONS: Medication What Year? How Many Months? Weight Lost Weight Regained Phen-Fen Pondimin (Fenfluramine) Redux (dexfenfluramine) Please note: The above three medications were withdrawn from the market in 1997 Adipex (Phentermine) Meridia (Sibutramine) Xenical (Orlistat) Didrex (Benzphetamine) Metabolife Other (name): Other (name): Please note: If you had an echocardiogram done in relation to intake of an obesity medication (for example Phen-Fen), we will need a copy of the report. Page 2 88-1813-2 (Rev. 3/19) COMPLETE ONLY IF YOU HAVE HAD WEIGHT LOSS SURGERY
8. WEIGHT LOSS SURGERY HISTORY: What bariatric surgery did you have? q Gastric Bypass q Sleeve Gastrectomy q Adjustable Gastric Band q Duodenal Switch q Vertical Banded Gastroplasty q Other ______
Date: ______Surgeon: ______Location: ______
What was your weight immediately before surgery? ______
What was your lowest weight after surgery? ______
How many months did it take you to acheive that lowest weight? ______
When did you start noticing weight going back up? ______
What is the highest weigth you notice dafter surgery? ______
Why do you think you regained weight?______
Can you currently eat a complete hamburger I one sitting? q Yes q No If yes, what size?______
With fries? q Yes q No If yes, what size?______
How many pieces of pizza can you currently eat at a time? ______What size? ______
9. ADJUSTABLE GASTRIC BANDS: Type of Band q Allergan Lapband APL 14cc q Allergan Lapband APS 10cc q Realize 9cc q Realize C 11cc Date of last adjustment ______Amount of fluid in your band ______CC Weight Lost/Gained in the past month ______LBS Weight Lost/Gained in the past year ______LBS
Do you hve any of the following: q Reflux q Nausea/Vomiting q Food getting stuck q Fevers/Chills q Skin changes around your port q Abdominal Pain q Weight regain
Do you feel that your band is working? q Yes q No Do you feel restriction when you eat? q Yes q No
10. GASTRIC BYPASS/SLEEVE GASTRECTOMY/DUODENAL SWITCHES: Weight Lost/Gained in the past month ______LBS Weight Lost/Gained in the past year ______LBS
Do you have any of the following: q Reflux q Nausea/Vomiting q Food getting stuck q Fevers/Chills q Abdominal Pain q Diarrhea q Food intolerance q Weight regain
Do you feel that your surgery is working? q Yes q No Are you taking your vitamins/supplements? q Yes q No Doo you feel restriction when you eat? q Yes q No When was the last set of nutritional labs: ______Last time you were seen by your weight loss surgeon: ______Page 3 88-1813-2 (Rev. 3/19) 11. FAMILY HISTORY: Do you have a family history of (check all that apply and DO NOT INCLUDE YOURSELF): q Diabetes q Coronary Heart Disease q Thyroid Disease q Adrenal Gland Disease q Blood clots in legs (DVT) q Blood clots in lungs (PE) q Obesity on your mother’s side of the family. Percentage: _____ q Obesity on your father’s side of the family. Percentage: _____ q Other significant family history: ______
12. EXERCISE HISTORY: Do you exercise routinely? q Yes q No What kind of exercise? ______How many times per week? ______For how long (minutes)? ______What equipment do you have access to: q Treadmill q Bike q Pool q Exercise video q Rowing machine q Elliptical machine q Other: ______How far can you walk on a flat surface before you have to stop? ______How many stairs can you climb before you have to stop? ______What makes you have to stop: (Check all that apply): q Shortness of breath q Tiredness q Chest pain q Pain in feet q Pain in legs q Pain in knees q Pain in hips q Pain in back
REVIEW OF SYSTEMS:
13. OB/GYN HISTORY: (Please check all that apply and complete where indicated) q Hysterectomy q Tubal ligation q Infertility issues q Polycystic Ovarian Syndrome (POS) Birth control method: ______Date of last menstrual period: ______Menstruation issues (check all that apply): q Colicky q Irregular q Scant q Heavy q Absent for 6 months or more at a time Number of pregnancies: ______Number of live births: ______Did your weight after pregnancy go remarkably above what it was before pregnancy? q Yes q No
14. HEART HISTORY: (Write “Unknown” if appropriate. Feel free to add comments) Condition Yes No What Year? Comments Heart attack Chest pain Heart murmur Enlarged heart Irregular heart beat Congestive heart failure Blood clots in legs (DVT) Blood thinner? How long? Blood clots in lungs (Pulmonary Embolism) Blood thinner? How long? Hypertension
Comments: ______Do you have a cardiologist? q Yes q No If yes, please provide their name, city, state and phone number: ______Page 4 88-1813-2 (Rev. 3/19) 15. LUNG HISTORY: (Write “Unknown” if appropriate. Feel free to add comments) Condition Yes No Comments Asthma q Allergy-induced q Exercise induced Type of inhaler: ______Last used: ______Frequency of inhaler use: Pneumonia When did you have it last? How often have you had it? Chronic Bronchitis When did you have it last? Emphysema Do you use an inhaler? q Yes q No Type of inhaler: ______Last used: ______Frequency of inhaler use: ______Pulmonary Hypertension When diagnosed? Sleep apnea When diagnosed? q CPAP or q BI-PAP ______Other (name) Comments: ______Do you have a pulmonologist? q Yes q No If yes, please provide their name, city, state and phone number: ______16. GASTROINTESTINAL HISTORY (Write “Unknown” if appropriate. Feel free to add comments) Condition Yes No Comments Upper abdominal pain Acid Reflux (aka. Heartburn, GERD) Esophagitis Hiatal Hernia Gastritis Peptic Ulcer (stomach, duodenum) Gallbladder Problems Crohn’s Disease Ulcerative Colitis Nausea &/or Vomiting Diarrhea How many bowel movements per day? Chronic Constipation How often do you have a bowel movement? Irritable Bowel Syndrome (IBS) Rectal Bleeding Stomach endoscopy (gastroscopy, EGD) Colonoscopy
Yes No Comments Sigmoidoscopy Barium stomach x-ray study Colon barium study (Barium Enema) Comments: ______Do you have a gastroenterologist? q Yes q No If yes, please provide their name, city, state and phone number: ______Please Note: We will need copies of the reports of any recent GASTROINTESTINAL radiology (e.g., barium tests) or endoscopy (e.g., gastroscopy Page 5 EGD, sigmoidoscopy, colonoscopy) studies, before your surgery is scheduled. You do not have to bring the copies during your first visit. 88-1813-2 (Rev. 3/19) 17. ENDOCRINE AND METABOLIC HISTORY: (Write “Unknown” if appropriate. Feel free to add comments) Condition Yes No Year diagnosed Comments Diabetes Type 2 Diabetes Type 1 Pre-diabetes, insulin resistance, abnormal glucose tolerance Hypoglycemic attacks Thyroid problems Adrenal Gland problems High cholesterol Other (name) Comments: Do you have an endocrinologist? q Yes q No If yes, please provide their name, city, state and telephone number: ______
18. BONES, JOINTS, RHEUMATOLOGY HISTORY: (Please check what applies. Write “Unknown” if appropriate. Feel free to add comments) Condition Yes No Worse with Comments weight gain? Upper back pain q Yes q No Disc space problem q Yes q No Arthritis q Yes q No Lower back pain q Yes q No Disc space problem q Yes q No Arthritis q Yes q No Neck spine pain q Yes q No Disc space problem q Yes q No Arthritis q Yes q No Hips q Yes q No Osteo-Arthritis q Yes q Knee pain q Yes q No Osteo-Arthritis q Yes q Ankle pain q Yes q No Foot pain q Yes q No Plantar fasciitis? q Yes q No Bunions? q Yes q No Rheumatoid disease q Yes q No Systemic Lupus q Yes q No Fibromyalgia q Yes q No Swelling of feet q Yes q No Ulcers of the legs q Yes q No Gout q Yes q No Other: q Yes q No Comments: Do you have a rheumatologist? q Yes q No If yes, please provide their name, city, state and telephone number: ______
19. GENITO-URINARY: Do you have problems with your bladder leaking urine when you cough, laugh, sneeze or strain? q Yes q No If yes, please explain: ______
20. RENAL: Do you have a history of kidney problems? q Yes q No If yes, please explain: ______
Page 6 88-1813-2 (Rev. 3/19) 21. SKIN: Do you have recurring or long-term skin problems? q Yes q No If yes, please explain: ______
22. LIVER: Do you have a history of liver problems? q Yes q No If yes, please explain: ______
23. NEURO-PSYCHIATRIC HISTORY: Condition Yes No Medication? Hospitalization? Comments? Depression Anxiety Panic attacks Self-esteem issues Seizure disorder Headaches (incl. migraines) Stroke Headaches Others:
Comments: Do you have a counselor or therapist? q Yes q No If yes, please provide their name, city, state and telephone number: ______
24. SLEEP HISTORY: Have you been diagnosed with sleep apnea? q Yes q No Were you started on CPAP or Bi-PAP treatment? q Yes q No If you answered NO to the questions above, please answer the following: Do you snore loudly?...... q Yes q No Have you been witnessed to momentarily stop breathing while asleep?...... q Yes q No Do you wake up very tired after 7-8 hours of sleep?...... q Yes q No Do you wake up gasping for breath?...... q Yes q No Do you fall asleep while driving a car?...... q Yes q No Do you fall asleep during daytime activities?...... q Yes q No Can you make it through an average day without taking a nap?...... q Yes q No
For Office Use ONLY: List of Co-Morbidities
Page 7 88-1813-2 (Rev. 3/19) 25. SURGERY HISTORY: *Weight loss surgery? q Yes q No Year: ______Type: ______(Laparoscopic? q Open? q) Gallbladder? q Yes q No Year: ______(Laparoscopic? q Open? q) Hysterectomy? q Yes q No Year: ______
Other Surgeries Year Comments/Problems
*Please Note: If you had previous weight loss surgery, we need a copy of the operative report, if at all possible. You do not have to bring it with you in your first visit if it is hard to find, but please realize that providing that record early on will allow us to make better decisions about your care.
26. MEDICATIONS: Please list all medications you currently take, including over-the-counter medications and herbal supplements. Be sure to include exact doses and frequency. Medication Dose Frequency
Have you taken steroids in the last 12 months? q Yes q No If yes, please provide details: ______
27. ALLERGY HISTORY: (Allergies, reactions and significant side effects with medications) Medication Name Type of reaction Was reaction life-threatening?
q Yes q No q Unknown q Yes q No q Unknown q Yes q No q Unknown q Yes q No q Unknown q Yes q No q Unknown
Are you allergic to latex? q Yes q No If yes, please provide details: ______
Page 8 88-1813-2 (Rev. 3/19) 29. SOCIAL HISTORY: Do you currently smoke? q Yes q No If yes, how many cigarettes per day? ______If no, have you smoked cigarettes in the past? q Yes q No If yes, when did you quit? ______Do you drink alcohol: q Yes q No Describe what kind of alcohol, how much and how often you drink: ______Do you have a history of drug abuse? q Yes q No If yes, how long have you been clean? ______
30. DIET HISTORY AND HABITS: Meals How many meals do you eat per day?______How many snacks do you eat per day? ______Do you have strong liking to sweet foods? q Not really q Sometimes q Often q Always Beverages Do you drink carbonated soft drinks? q Yes q No If yes, how many of each per day: ____ Diet ____Regular Do you drink coffee? q Yes q No If yes, how many cups of each per day: ____ Regular ____Decaffeinated Do you drink tea? q Yes q No If yes, how many cups of each per day: ____ Diet ____Regular How much water (including flavored calorie-free water) do you drink per day? ______Eating issues Do you have binge eating disorder (a compulsive, uncontrolled urge to eat more than needed to satisfy hunger)? q Yes q No Do you have Bulimia (repeated episodes of binge eating, followed by self-induced vomiting)? q Yes q No ______
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