PATIENT INFORMATION Name______Social Security # ______Last Name First Name Middle Initial
Sex Male Female Date of Birth: ______Aliases: ______
StreetAddress/City/State/Zip______
Mailing address (if different than above) ______
Home Phone ( ) ______Cell Phone ( ) ______Can we leave messages? Yes No
E-mail address ______
Interpreter Needed? Yes No Marital Status Divorced Legally Separated Married Single Widowed Other ______Ethnicity: American Indian Hispanic or Latino Patient Refused Unknown Other ______Race: American Indian or Alaska Native Asian Black or African American White or Caucasian Native Hawaiian or Other Pacific Islander Other Patient Refused Unknown Primary Language English Spanish Other ______Religion: ______
Primary Care Provider: ______Address:______Phone Number: ______
Emergency Contact ______Phone ( ) ______Relationship______Additional Contact ______Phone ( ) ______Relationship______
Employer:______Address: ______Phone Number: ______Employment Date: (From)______(To) ______Status: Disabled Full Time Part Time Retired Other
Guarantor (Party Responsible for Bill) Self Employer Spouse Father Mother Other Name:______SSN#:______Address: ______1 NAME:______DOB:______Home Phone:______Work Phone: ______Cell Phone: ______Date of Birth: ______Sex: Male Female
INSURANCE INFORMATION Primary Insurance ______Secondary Insurance ______ID # ______Group # ______ID # ______Group # ______Telephone ( ) ______Telephone ( ) ______Insured Name ______Insured Name ______Insured DOB ______Sex M F Insured DOB ______Sex M F Relationship to Patient: ______Relationship to Patient: ______Third Insurance (if any) ______*** A copy of your insurance card and photo ID is required for billing*** If this is a Workman’s Comp/Injury (more information may be requested) Date of Injury ______Docket/Claim number ______Contact Person ______I acknowledge that I have been given the right to review and secure a copy of the Notice of Privacy Practices. I understand that the organization reserves the right to change the terms of this notice.______(Initial)
______Signature of Patient/Guardian Date
How did you hear about us? Please check one: I am interested in: Friend/Family member Gastric Bypass Physician Referral (Please provide Lap Band name of Gastric Sleeve provider)______ Undecided Internet Search Newspaper ad Television Other (Please specify) ______
2 NAME:______DOB:______INITIAL PATIENT HISTORY FORM
Current Weight: lbs Current Height: feet inches This entire gray section is for Office Measurements and Calculations Date: office purposes only
Today’s Weight ______lbs Ht: ______feet ______inches BMI: Ideal Body Weight ______lbs Excess Body Weight: ______lbs
Percent Ideal Body Weight______% 80% of Excess Wt. = Estimated Goal Wt: ______lbs.
WEIGHT & DIETING HISTORY
Please estimate as closely as possible for all that applies. 1. Approximate age when you first became overweight: ______years old. 2. How long have you been at your current weight? ______Years ______Months 3. Most recent weight loss attempt was doing______Are you still currently doing this? _____yes _____no If not, list dates of this attempt: ______DIET AND EXERCISE HISTORY
DIETS (Please list the diets and diet programs you have tried. Provide as many details as possible): Medications/Pills Dates Supervised? Wt Lost Wt Re-gained Dexatrim Yes □ No □ Yes □ No □ Fen/Phen /Redux Yes □ No □ Yes □ No □ Xenical / Alli Yes □ No □ Yes □ No □ Phentermine: Yes □ No □ Yes □ No □ Other: Yes □ No □ Yes □ No □ Other: Yes □ No □ Yes □ No □ Other Diets/ Programs Dates Supervised? Wt Lost Wt Re-gained Jenny Craig Yes □ No □ Yes □ No □ Nutri-Systems Yes □ No □ Yes □ No □ Opti/Medi Fast Yes □ No □ Yes □ No □ T.O.P.S. Yes □ No □ Yes □ No □ Weight Watchers Yes □ No □ Yes □ No □ Slim Fast Yes □ No □ Yes □ No □ Atkins Diet Yes □ No □ Yes □ No □ Grapefruit Diet Yes □ No □ Yes □ No □ Herbalife Yes □ No □ Yes □ No □ High Protein Diet Yes □ No □ Yes □ No □ Low Calorie Diet Yes □ No □ Yes □ No □ South Beach Yes □ No □ Yes □ No □ Cabbage Soup Diet Yes □ No □ Yes □ No □ Other: Yes □ No □ Yes □ No □ Other: Yes □ No □ Yes □ No □ Other: Yes □ No □ Yes □ No □ Other: Yes □ No □ Yes □ No □ Other: Yes □ No □ Yes □ No □
3 NAME:______DOB:______Types of exercise IMPORTANT: Please give details and a summary of your exercise attempts and experience:
□ Aerobics □ Bicycling □ Free Weights □ Nautilus □ Jogging □ Swimming □ Walking □ Spinning Do you belong to a fitness center? Yes □ No □ □ Yoga If not currently, have you ever in the past? Yes □ No □
Eating Disorders Bulimia Yes □ No □ Details:
Laxatives or Diuretics Yes □ No □ Details: used for weight loss Compulsive Overeating Yes □ No □ Details:
Other Yes □ No □ Details:
List any MEDICALLY SUPERVISED Weight Loss attempts (list only those that were supervised by a physician, nurse practitioner, or physician’s assistant):
Supervising Provider Dates Length of Weight Weight MEDICALLY SUPERVISED Name: Month / year Program Lost Re-gained to (months) DIET City: State: Month / year
Prescription weight loss drugs Exactly what diet or type of program did you follow during this time? used during this diet: How often did you see the Medical practitioner during this diet?
Supervising Provider Dates Length of Weight Weight MEDICALLY SUPERVISED Name: Month / year Program Lost Re-gained to (months) DIET City: State: Month / year
Prescription weight loss drugs Exactly what diet or type of program did you follow during this time? used during this diet: How often did you see the Medical practitioner during this diet?
Medication Consideration (Please check all that apply): I have tried prescription weight loss medications in the past and did not tolerate them or was unsuccessful on them. I I have tried over-the-counter weight loss medications in the past and did not tolerate them or was unsuccessful on them. Because of other medical conditions I have, my primary care physician or practitioner does not believe I am a good candidate for prescription weight loss medications at this time. I am not interested in taking presciption or over-the-counter weight loss medication because of possible side-effects.
4 NAME:______DOB:______WEIGHT RELATED ILLNESSES Please just make any medical conditions that you have diagnosed with by a medical provider.
ALL PATIENTS: PLEASE FILL OUT THE FOLLOWING SECTIONS
1. High Blood □ On dietary restrictions for high blood pressure Explain:______Pressure ______Yes □ No □ Comments (For Office Use Only):
If Yes please explain or check all that are applicable: 2. Cardio / Vascular □ Congestive Heart Failure □ Angina (exertional chest pain) Disease □ Peripheral Vascular Disease / Stroke □ Coronary Artery Disease Yes □ No □ □ M.I. (myocardial infarction, heart attack) □ CABG (coronary artery bypass graft surgery) □ Leg Swelling/Edema □ Other:
Comments (For Office Use Only):
3. High Cholesterol □ If “Yes” but not currently on medication to lower cholesterol or triglycerides, please explain how High Triglycerides controlled: Yes □ No □ ______
Comments (For Office Use Only):
4. Type 2 Diabetes □ Treatment of Diabetes is with ____Oral Meds Only ____Insulin Only ____ Both Oral Med and Insulin Yes □ No □ □ If not Diabetic: Have been told you have Pre-Diabetes / Insulin Resistance Yes □ No □
Comments (For Office Use Only):
5. Sleep Apnea □ I have had a sleep study test Syndrome □ I use a CPAP / BIPAP Yes □ No □ □ I use oxygen at night ______For office use only: SLEEP APNEA SCREENING: For Office Use only Positive s/s of Sleep Apnea Yes □ No □ Comments (For Office Use Only):
6. COPD If “Yes”, please explain how you treat it: ______Chronic Obstructive Pulmonary Disease Yes □ No □
5 NAME:______DOB:______Comments (For Office Use Only):
7. Heartburn /GERD If “Yes” how often do you have symptoms? ______Yes □ No □ What causes your symptoms? ______H. Pylori? Yes □ No □ Comments (For Office Use Only):
8. Back pain I have joint pain in my: □ Hips □ Knees □ Ankles □ Feet □Other: ______Joint Pain Yes □ No □ If “Yes”, how often: ______
If “Yes”, how do you treat it: ______
Do you ever use assistive devices to walk or use a wheelchair? Yes □ No □ If “Yes” please explain: ______
Comments (For Office Use Only):
9. Depression Any other type of Mental Health Diagnosis? Yes □ No □ Yes □ No □ Any type of drug addiction? Yes □ No □ If so, please explain?______
Comments (For Office Use Only):
10. Obesity Related □ Rash under breasts Skin Problems □ Rash under arms Yes □ No □ □ Rash under abdominal folds of skin □ Rash in groin area □ Other:______
Comments (For Office Use Only):
6 NAME:______DOB:______PAST MEDICAL HISTORY
Other Medical Problems (not already Date Diagnosed How it is treated mentioned above) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
PAST SURGICAL HISTORY Date 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Please list any complications you had with any of the above surgeries or procedures: ______
7 NAME:______DOB:______MEDICATIONS Please list all medications you are currently taking including over-the-counter & herbal remedies
Medication Name Dosage How often taken Reason I take this medication 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
ALLERGIES
□ I have no known drug allergies □ I have allergies to the following MEDICATIONS: ______Type of reaction:______
______Type of reaction:______
______Type of reaction:______
______Type of reaction:______
______Type of reaction:______
□ I have an allergy to latex □ I have an allergy to surgical tape □ I have “hay fever” type allergies to the environment □ I have the following FOOD allergies: ______Type of reaction:______
______Type of reaction:______
______Type of reaction:______
______Type of reaction:______
8 NAME:______DOB:______SOCIAL HISTORY
Occupation □ Retired Disabled If “Yes” please explain ______Date of Disability: Yes □ No □ ______Marital status □ Single □ Married □ Divorced □ Widowed □ Significant Other
Children Age Daughter or son Age Daughter or son
Yes □ No □ Is your spouse/significant other aware and supportive of your decision to consider weight loss surgery?
Support System Please describe your social support system (spouse, friends, family, people you know who have had weight loss surgery) you may rely on after surgery:______
______
If you DO use tobacco - 1. Do you use tobacco? Yes □ No □ How much per day do you use? ______For how many years ______If Yes, what type: □ Cigarettes Are you willing to quit? Yes □ No □ □ Cigars □ Chewing tobacco If you DID use tobacco- □ Pipe When did you quit? ______How many packs/cans per day did you use? ______For how many years did you use it? ______
2. Do you drink alcohol? How often? ______Yes □ No □ How much? ______Do you drink alcohol on most every day? Yes □ No □ How much in the average week? ______History of alcohol dependency? Yes □ No □ If so, when? ______
If Yes, please give details: 3. Have you used illicit drugs? Yes □ No □ Have you injected illicit drugs? Yes □ No □
How recently have you used illicit drugs?
9 NAME:______DOB:______FAMILY HISTORY
Family Current Age Cause of Death Family history of disease / Illness Member Age Deceased Obese? Yes □ No □ Mother Other Medical Problems:
Obese? Yes □ No □ Father Other Medical Problems:
Obese? Yes □ No □ Maternal Other Medical Problems: Grandmother
Obese? Yes □ No □ Maternal Other Medical Problems: Grandfather
Obese? Yes □ No □ Paternal Other Medical Problems: Grandmother
Obese? Yes □ No □ Paternal Other Medical Problems: Grandfather
Sibling Obese? Yes □ No □ Other Medical Problems: Bro Sis Sibling Obese? Yes □ No □ Other Medical Problems: Bro Sis Sibling Obese? Yes □ No □ Other Medical Problems: Bro Sis Sibling Obese? Yes □ No □ Other Medical Problems: Bro Sis Sibling Obese? Yes □ No □ Other Medical Problems: Bro Sis Child Obese? Yes □ No □ Other Medical Problems: Son Dtr Child Obese? Yes □ No □ Other Medical Problems: Son Dtr Child Obese? Yes □ No □ Other Medical Problems: Son Dtr Child Obese? Yes □ No □ Other Medical Problems: Son Dtr Child Obese? Yes □ No □ Other Medical Problems: Son Dtr
10 NAME:______DOB:______REVIEW OF SYSTEMS (Check symptoms which you have PRESENTLY. For positive responses, please give details.)
General: ______Sleep Disturbances _____Fatigue _____Fever _____ Chills
Explain:
Head, Eyes, Ears, Nose Throat: _____Neck pain _____Hearing Loss/Changes _____Ear Pain _____Ringing in the Ears _____Nosebleeds _____Congestion / Nasal Drainage _____Dental problems _____Mouth Sores _____Sore Throat _____Voice Changes _____Trouble Swallowing _____Eye Pain / itching /redness _____Visual Changes _____Sensitivity to Light
Explain:
Respiratory: _____Shortness of Breath ______Cough _____Wheezing _____Chest Tightness
Explain:
Cardiovascular: ______Chest Pains ______Palpitations (irregular heart beats) _____Leg Swelling
Explain:
Gastro-Intestinal: _____Heartburn _____Abdominal Pain _____Blood in Stool _____Nausea / Vomiting _____Constipation _____Diarrhea
Explain:
Urinary: _____Difficulty Urinating _____Pain with urinating _____Blood in Urine _____Frequency _____Urgency _____Stress Incontinence
Explain:
Reproductive (Women Only): Number of Pregnancies: ______Number of Live Births: ______Miscarriages/abortions: ______Last menstrual period: ______Last Pap: ______Last Mammogram: ______Use Birth Control: Yes No Planning Additional Pregnancies: Yes No ______Irregular Menstrual Cycles ______Abnormal Pain with Cycles
Reproductive (Men Only): _____Penile Pain/Swelling _____Testicular Pain/Swelling _____Enlarged Prostrate
11 NAME:______DOB:______Muscle / Skeletal: _____Muscle Aches _____Joint Pain/Aches _____Joint Swelling _____Back Pain _____Gait Problems
Explain:
Skin: _____Color Changes _____Dryness _____Rashes _____Wound Problems
Explain:
Endocrine: _____Cold Intolerance _____Heat Intolerances _____Excessive Thirst
Explain:
Neurological: _____Headaches _____Dizziness/Lightheadedness _____Numbness / Tingling _____Passing out _____Tremors _____Weakness
Explain:
Hematologic: _____Easy Bruising _____Excessive Bleeding _____Sore / Swollen Lymph Glands
Explain:
Psych: _____Agitation _____Behavior Problems _____Difficulty Concentrating _____Anxiety / Nervousness _____Depression _____Thoughts of Suicides
Explain:
12 NAME:______DOB:______PLEASE LIST ALL PHYSICIANS WHOSE CARE YOU ARE OR HAVE BEEN UNDER FOR THE PAST 5 YEARS:
Make sure to give complete addresses for these physicians. We will be sending requests for your medical records of weight- related appointments and treatments. Failure to provide complete addresses could result in this form being returned to you for completion which could slow down your interview process. For insurance reasons, it is imperative that we have the past 5 years of your medical history. If you have not been a patient of your primary care doctor/practitioner for at least 5 years please give us the information of the other primary care doctors/practitioners whose care you have been under.
Primary Care Name: Phone: Fax: Doctor/Practitioner Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Primary Care Name: Phone: Fax: Doctor/Practitioner Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Primary Care Name: Phone: Fax: Doctor/Practitioner Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Internist Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: OB/GYN Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Orthopedist Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Cardiologist Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Pulmonologist Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Gastroenterologist Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Psychiatrist Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Psychologist Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Counselor/Therapist Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Other: Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to: Other: Name: Phone: Fax: Street: City: State/Zip: Current provider? Yes □ No □ I have been/was under the care of this practitioner from: to:
13 NAME:______DOB:______