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9 Entered into electronic record after downtime ______________ ______________ date time DOWNTIME ______________ initials BARIATRIC APPLICATION PACKET 1 OF 2 Patient ID Area COMPREHENSIVE WEIGHT LOSS MANAGEMENT APPLICATION This form to be completed by patient. It must be received before you can be scheduled for your initial visit. The Center for Minimally Invasive Surgery Buffalo General Medical Center 100 High Street, Buffalo NY, 14203 Attn: D3 CWL Clinic Application Office Application Information Phone: (716) 859-2067 Application Fax: (716) 859-3352 Applications can be mailed or faxed to the address or fax number above. Patient Name Date of Birth Telephone Number (home) (cell) (work) Height (inches) Weight (pounds) Sex 9 Male 9 Female Transgender 9 Male to Female 9 Female to Male Address Primary Medical Doctor Insurance Company and ID number At what age did you first consider yourself overweight? What was your heaviest documented weight? Which diet plans have you attempted in your lifetime? 9 Jenny Craig 9 South Beach Diet 9 Cabbage Soup Diet 9 App-based Diet Plan 9 Weight Watchers 9 Slim Fast 9 Dietician Directed Plan 9 Nutrisystem 9 Atkin’s Diet 9 Grapefruit Diet 9 Physician Directed Plan 9 Intermittent Fasting 9 Keto Diet 9 Paleo Diet 9 Other Which exercise plans have you attempted? 9 Curves for Women 9 Richard Simmons Tape 9 Gold’s Gym 9 Video Workout 9 Peloton 9 Personal Trainer 9 Buffalo Athletic Club 9 Beachbody 9 Walking 9 iFit 9 Gym Membership 9 Other Which medications/dietary supplements have you used to lose weight? 9 Phen-Fen (phentermine and fenfluramine) 9 Xenical (orlistat) 9 Saxenda 9 Topomax 9 Meridia (sibutramine) 9 Amphetamine 9 Ozempic 9 Other (over) KH01038 Rev. 03/17/21 INTAKE 9 Entered into electronic record after downtime ______________ ______________ date time DOWNTIME ______________ initials BARIATRIC APPLICATION PACKET 2 OF 2 Patient ID Area Several medical problems can be related to weight. Do you have any of the conditions listed below? 9 High blood pressure 9 High cholesterol 9 Shortness of breath on exertion 9 Sleep apnea 9 Asthma 9 Diabetes 9 Acid reflux (GERD) 9 Bladder problems 9 Joint pain 9 Depression 9 Other Please provide an accurate and complete medication list including dosage and frequency. An attached list is sufficient. Medication Dose Frequency List all medical and environmental allergies and your corresponding allergic reaction Have you ever had surgery? (please list) Do you smoke? 9 No 9 Yes How much per day? For how many years? Do you drink alcoholic beverages? 9 No 9 Yes How much, and how often? Do you use any illicit/recreational drugs? 9 No 9 Yes (explain details) Have you ever had a drug or alcohol problem? 9 No 9 Yes (explain details) Signature Date Time Print Name Relationship to Patient (if not completed by patient) KH01038 Rev. 03/17/21 INTAKE.

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