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New Dietitian Consult: Bariatric Surgery

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New Dietitian Consult: Bariatric Surgery Checking Your Insurance Benefits IMPORTANT Please check your insurance coverage prior to any Nutrition or Diabetes Education appointment. You will be responsible for any services that are not covered. Call the number on the back of your insurance card and give them the following information: 1. You are being seen at Community Health and Life Center, PLLC. The dietitian NPI # is 1417431644. The office NPI # is 1609369172. The office TAX ID # is 83-0675758. 2. You will be billed as *OUTPATIENT CONSULTATION* NOT a physician visit. 3. The procedure codes are: o Medical Nutrition Therapy with a Registered Dietitian: (Nutrition Diagnosis ONLY: Check the 2 procedure codes below.) . 97802 (Initial Visit) . 97803 (Follow Up Visit) 4. Tell them you need monthly visits to discuss your weight: One Per Calender Month, 30-days Apart, Consecutive - In Order, No Breaks 5. Be sure to ask for the representative’s first name and last initial and a reference number for the call. Document the date of the call for your files. 6. Additional questions to ask your insurance company: o Any limitations on visits and how many visits per calendar year are allowed? If visits are limited, are there different limits for the Diabetes Nurse and the Registered Dietitian? o Are Referrals or Pre-Certification required? If a referral is needed, please call your doctors office and bring it the day of your appointment. If you need a Pre-Certification please contact us. o What is your responsibility: co-pay, co-insurance, or deductible? o Be sure to ask for the representative’s first name and last initial, a reference number for the call and document the date of the call. If your insurance informs you that our services are NOT a covered benefit please call our center so that we may discuss other options or have your insurance company representative contact our office at 346-616-0038. **Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you! Weight Loss Surgery Nutrition Screening Evaluation Form Name: _______________________________ Age: ______ Birth Date: ____________ Bariatric Surgeon: ____________________________ Surgery Planned: Roux-en-Y Gastric Bypass Sleeve Gastrectomy Other: __________________ Cell Phone: ___________________ E-mail Address: ___________________________ Gender: Male Female Live with: Spouse Family Friend Alone Employment: Full-time Part-time Retired Student Other__________ Occupation: ___________________________________ Work Hours: ______________ Have you seen a dietitian before? Yes No If yes, for what diet? _________________ When? ___________ Where? __________ Have you had any previous weight loss surgeries? Yes No If yes, what type(s)? When? Height: _______ Present Weight: ________ BMI (if known):_______ Highest adult weight: ________ Date: _________________ Lowest adult weight: ________ Date: _________________ Recent weight change? Yes No How many pounds lost? ____ Gained? ____ What would you like to weigh? ______________ How much weight do you expect to lose as a result of weight loss surgery? Less than 50 lbs. 50-100 lbs. 100-150 lbs. More than 150 lbs. What age did you begin to gain excess weight? _______________________________ Looking back, what would you attribute the weight gain to at that time?________________________________________________________________ Dietitian to complete: % estimated weight loss/surgery type_________________ Weight loss expected: _______________ Goal weight range: _______________ © 2019 Community Health and Life Center, PLLC. All right reserved worldwide. CHLC - Nutritional Services 1 Weight Loss Surgery Nutrition Screening Evaluation Form Check any of the following problems you had previously or are now experiencing: Hearing Problems Heart disease Asthma Memory/Concentration High Blood Pressure Kidney Disease Blurred Vision Congestive Heart Failure Pre-Diabetes Problems Reading Stroke Diabetes: Type 1___ Reflux/ Heartburn High Cholesterol Type 2 ___ Hiatal Hernia Anemia Thyroid disease Polycystic Ovary Syndrome Anxiety/Depression Excessive Thirst Constipation/ Diarrhea Mental Health Problems Frequent Urination Nausea/ Vomiting Liver Disease Sleep Apnea Colon Surgery Back, Knee, Hip Problems Cancer Loss of Feeling/Tingling/ Pain in: __Feet __Legs __Hands __Arms Please list any other medical problems or surgeries (not listed above). Also, include any medical procedures (such as balloon angioplasty): ___________________________________________ For women: Are you currently pregnant? Yes No Are you planning to become pregnant? Yes No Are you currently breastfeeding? Yes No Age at menopause: __________ Check all over-the-counter medications you take: Multi-vitamins: brand:________________________________ Single vitamins (Vitamin C, E, etc.): type(s):____________________________________ Calcium: type: ______________________________amount:________________________ Herbs: type(s):_______________________________________________ Other over-the-counter medications:____________________________________________ Write down all the prescription medications you take. 1.________________________ 5.________________________ 2.________________________ 6.________________________ 3. ________________________ 7.________________________ 4.________________________ 8. ________________________ © 2019 Community Health and Life Center, PLLC. All right reserved worldwide. CHLC - Nutritional Services 2 Weight Loss Surgery Nutrition Screening Evaluation Form On a scale of 1 -5, circle the number that best describes you or your situation. Neither Agree nor Disagree Strongly Disagree Disagree Agree Strongly Agree I have family and friends that will be a strong support system for me after surgery. 1 2 3 4 5 I have researched bariatric surgery and talked with people who have had weight loss surgery. 1 2 3 4 5 I will be involved with my follow-up care and attendance at bariatric support groups after surgery. 1 2 3 4 5 I am highly motivated. 1 2 3 4 5 I am quick to learn and can easily follow directions. 1 2 3 4 5 1. Have you ever been diagnosed with an eating disorder? Yes No If yes, what type? Binge Eating Anorexia Nervosa Bulimia Other: _______________________ 2. Do you drink alcoholic beverages? Yes No If yes, how often? ________________ If yes, what do you drink? Beer (regular) Beer (light) Wine Mixed drinks Brandy Liquor (Gin, Rum, Vodka) Liqueur (Kahlua, Bailey’s, Crème de Menthe) 3. Do you use marijuana, cocaine, crack or other recreational drugs? Yes No 4. Do you smoke? Yes No If yes, how much do you smoke in 24 hours? _____________ If no, have you ever smoked? Yes No If yes, when did you quit? ____________ 5. How many hours do you usually sleep (out of a 24 hour day)? ____________ What time do you get up? _________ What time is your first meal? _______________ 6. Do you have any food or medication allergies? Yes No If yes, please list: ________________________________________________________ 7. Do you follow any religious or cultural rules that influence what or how you eat? Yes No If yes, please explain: _______________________________________ 8. How do you learn best? Verbal (explanation/tapes/video) Demonstration Written (books/pamphlets/guidelines) Other (please explain):_____________ © 2019 Community Health and Life Center, PLLC. All right reserved worldwide. CHLC - Nutritional Services 3 Weight Loss Surgery Nutrition Screening Evaluation Form Please check () everything below that describes your diet and/or lifestyle behaviors: 1. I eat large portions, get seconds, or 11. I eat too quickly, chew foods poorly overfill my plate. or take too large of bites. 2. I skip meals or go for longer than five 12. I am an emotional eater or I eat hours between meals. more when I am stressed. 3. I dine out (includes carry-in) more 13. I drink less than 64 ounces (8 cups) than three times a week. daily (all fluids count). 4. I frequently eat fried foods, fast 14. I gulp (rather than sip) my foods, and high fat foods. beverages or drink too quickly. 5. I frequently eat sweets and desserts 15. I drink beverages with calories (candy, cakes, cookies, pies). (juice, punch, soda, sweet tea, etc.). 6. I graze (snack on food all day long) 16. I usually drink more than two while doing other things (reading, carbonated drinks (soda pop, computer work, watching TV). bubbly drinks) daily. 17. I usually drink more than two cups 7. I eat high calorie snacks. of coffee or caffeine drinks daily. 8. I wake up and eat during the middle 18. I usually drink two or more alcoholic of the night. beverages daily. 9. I don’t eat enough protein (less than 19. I lack sufficient exercise (less than 4-6 ounces of meat, fish or poultry 30 minutes on most days of the daily). week). 10. I get less than three dairy servings 20. Other: (milk, yogurt, cheese) daily. Dietitian to fill out: Pre-surgery goals selected: _________________________________ © 2019 Community Health and Life Center, PLLC. All right reserved worldwide. CHLC - Nutritional Services 4 Weight Loss Surgery Nutrition Screening Evaluation Form Please check () those statements below that apply to you. Identifying problem areas before surgery is the first step towards being successful after surgery. I have a relative or friend who may In the past I have not been good about try to hinder my weight loss efforts. taking vitamins and/or medications. I rely on someone else to purchase English is not my first language. I have and/or prepare my food. a language
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