Patient History Questionnaire

3226 F Hampton Avenue Brunswick, Georgia 31520 Telephone (912) 264-9724 Fax (912) 264-4071

Patient History Questionnaire The information requested in this questionnaire is very important. To give you the best care and to obtain your insurance approval, we must have complete answers. If you are visually or otherwise impaired and must use an assistant, please indicate his/her name below. Your name:______Date of Birth:______Person assisting with this form and relationship to you:______Date:______Age:______Height:______Weight:______

Approximately how long have you currently been at least 80-100 pounds overweight? ______years______months

Diet History

Approximate age when you first dieted:______List the diets and weight loss programs you have tried: Program Dates Duration MD supervised? Max loss Jenny Craig ______Nutri-Systems ______Weight Watchers ______OptiFast ______MediFast ______Fen/Phen/Redux ______Meridia ______Lindora ______T.O.P.S. ______O.A. ______Metabolife ______Atkins ______Pritikin ______Hypnosis ______Acupuncture______

1 Name: ______

List any other weight loss attempt(s) your physician supervised and documented: ______

List any others diets and/or weight loss methods you’ve tried:______

In your own words, please describe what you hope to accomplish and how you believe your life will change by losing weight:______

Medications: Be sure to list your correct dosages and strengths. Also include any over- the-counter medications, herbal and dietary supplements you take. 1.______2.______3.______4.______5.______6.______7.______8.______9.______10.______11.______12.______13.______14.______15.______

Do you take Goody Powders, aspirin, NSAIDs (Motrin, Aleve, etc.) or other aspirin- based products on a regular basis? Yes___ No___. If yes, which ones and how often? ______

Medical Conditions/Diseases: Have you had or do you have any of the following illnesses or conditions? If so, please briefly explain treatment you received:

Heart disease: Angina Treatment:______Heart Attack (MI):When:______Coronary artery bypass(CABG):When:______Hospital:______Coronary angioplasty or stents: When:______Hospital:______

2 Name:______

Heart disease continued: Abnormal EKG: Treatment:______Stress test Abnormal?______If yes, when and where done?______Palpitations/heart murmur/valve problem Treatment:______Heart failure, CHF Treatment:______Other:______

Lung/Pulmonary disease: Asthma______COPD (chronic obstructive pulmonary disease)______Sleep apnea If yes, CPAP or BiPAP used or recommended?______What settings are used?______mm water Pneumonia______After surgery?_____yes_____no Other______

Gastrointestinal disease: Ulcer/bleeding ulcer Treatment:______Acid reflux/GERD(gastroesphogeal reflux disease)______Irritable bowel syndrome______Colitis/diverticulitis______Other______

Kidneys/bladder: Kidney stones______Renal insufficiency/failure (chronic or acute)______Urinary retention (particularly after surgery)______Urinary incontinence (leakage)______Other______

Vascular (blood, blood vessels): High blood pressure Is it well controlled?______High cholesterol______High triglycerides______Clots in legs (DVT)______Clots in lungs (pulmonary embolus)______Anemia______Free bleeder/hemophiliac______Blood transfusion in the past______Venous stasis disease/ulcers______Other______

3 Name:______

Endocrine: Diabetes mellitus Year diagnosed______Oral medication?______Insulin injections?______Date and value of last hemoglobin A1c:______Under-active thyroid______Other______

Nervous System: Migraine headaches______Neuropathy______Slipped/degenerative disk______Stroke______TIAs (mini-strokes)______Seizure disorder______Other______

Muscle/Joint/Skeletal disease: Arthritis______Where affected______Rheumatoid arthritis______Lupus (SLE)______Gout______Spine disease______Degenerative joint disease______Fractures______Fibromyalgia______Other______

Infectious Disease: Staph infection______Hepatitis______HIV infection______Tuberculosis (TB)______Other______

Mental Health: Depression______Bi-polar______Panic disorder______Schizophrenia______Other______

4 Name:______

Allergies: List any drug allergies or intolerances you know of and the effect(s) they cause:______

Are you allergic to (circle): tape Latex iodine Other/food allergies:______

Surgical History:

Gallbladder removal:______Open(large incision)?______Laparoscopic______Abdominal:______Orthopedic/spinal:______Head/neck/throat:______Chest/breast:______Pelvic/urinary tract:______Plastic surgery:______Other surgery not listed above:______

Did you have any significant complications with any of your operations (infection, bleeding, anesthesia reaction, breathing/lung problems)?______

Hospitalizations:

Please list any admission(s) and the approximate dates and the reasons(s) other than the surgeries listed above:______

Family Medical History:

Please list any conditions that tend to run in your family:______Did anyone in your immediate family suffer a heart attack before the age of 50?______

Social history:

Have you ever used tobacco? Yes___No___ What type?______When did you quit?______Approximately how many total years did you use tobacco?______Do you use or have you ever used intravenous (IV)drugs?______Do you use or have you used illegal drugs?______Who resides with you in your household?______Do you have any religious objections to medical treatment? Yes___No___If so, what?______Do you drink any form of alcohol? Yes___No___If so, how many drinks of beer, wine or liquor have you had in the past 7 days?______Past one month?______

5 Name:______

What do you do in life (your occupation, hobbies, recreation, etc.)?______

Who is your power of attorney for medical decisions (the person you would want to make decisions regarding your healthcare in the case that you cannot)?______

Review of Systems:

Please circle the symptoms or problems below that you experience on a frequent basis or have experienced in the last three to four weeks. If you are unsure, please place a question mark beside that item.

Constitutional: Skin: weight gain rash fatigue change in size/color of mole loss of appetite lumps weight loss night sweats fever/chills weakness

Neurologic: Lungs/Breathing: headache/migraine short of breath at rest tingling/numbness coughing up blood seizures trouble breathing with exertion insomnia stop breathing during sleep memory loss dizziness trouble walking wheezing change in hearing or vision chronic cough weakness on one side snoring

Blood/Blood Vessels: Bladder/Kidneys: easy bruising urgent need to urinate easy bleeding urinary retention, especially after anesthesia bladder leaks when sneezing/laughing, etc. painful or difficult urination blood in urine recurrent infections of bladder or kidneys

6 Name:______

Review of Systems continued:

Ears, Nose and Throat: Heart: colds dizziness chronic cough chest pain nose bleed palpitations (rapid or fluttering heart beat) change in voice leg swelling sore throat loss of consciousness ringing in ears pain in legs after walking trouble swallowing dentures loose teeth

Stomach/Bowels: abdominal pain diarrhea acid reflux constipation nausea black, tar-like stool vomiting vomiting blood difficulty swallowing change in bowel habits pain in abdomen after eating blood in stool heartburn

Muscles/Joints/Bones joint stiffness leg cramps joint pain joint swelling back pain balance problems inability to move extremity muscle pain or weakness

Psychiatric/Emotional high stress memory loss sleeping more/less sadness thoughts of suicide victim of mental or physical abuse use illegal drugs or alcohol to cope with stress take no pleasure in life

7 Name:______

Female Reproductive heavy or painful periods infertility irregular periods number of pregnancies #______number of live births #______number of miscarriages #______complication of pregnancy (high blood pressure, diabetes, toxemia) date of your last normal period______birth control method______

So that we may provide you with the best possible care, is there anything else you would like us to know about your health or situation?______

Revised 6/15/07