New Dietitian Consult: Bariatric Surgery

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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: ______

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. ______

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):______

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: ______

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 barrier. I have problems with chewing and My calorie intake is already low (below swallowing. 1000 calories per day). I have a physical condition(s) that I am a stress eater or emotional eater. limits activity or exercise. I have problems with eyesight or I have an eating disorder. hearing. I never feel full even when I have eaten I have a difficult work schedule. a lot. I may not be able to afford I am addicted to food. supplements. I would have a difficult time reducing I have difficulty making changes. or giving up: ______.

Other: Other:

Please complete the following sentences: 1. The main reason I have been unable to lose weight (or maintain lost weight) is because: ______2. I want to lose weight (or I have decided to have weight loss surgery) because ______3. Questions I would like to discuss with the dietitian are: ______

Sample Menu (Use as an example to fill out the menu below): Time Meal Foods and Beverages Include Amounts and How Food is Prepared 8:00 a.m. Breakfast 1 cup coffee with 3 teaspoons sugar and one creamer Large toasted bagel with 2 tablespoons cream cheese 9:30 a.m. Snack 20 ounce soda pop Wendy’s Chicken BLT Salad with 2 packets of honey mustard 11:30 a.m. Lunch dressing and croutons 20 ounce lemonade + refill Pretzels, grab-it size 2:00 p.m. Snack 16 ounce bottle cranberry juice 2 fried chicken breasts, extra crispy ½ c. green beans with ham 7:30 p.m. Dinner 1 cup mashed potatoes with ¼ cup gravy 2 biscuits with 2 tablespoons butter 2 tablespoons honey 2 cans of beer 6 Oreo Cookies 11:00 p.m. Snack 12 ounces 2% milk

Describe your usual daily eating pattern: Time Meal Foods and Beverages Include Amounts and How Food is Prepared

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Name: Height: ______Weight: ______Date: ______

Insurance companies often require a list of diets followed within the past 5 years. The best you can remember, please complete the form below. Refer to the last page for a list of popular diets. Who Supervised Year You Number of Name or Type Pounds This Diet? Began Months on of Diet Lost (Name of This Diet This Diet Doctor/Facility)

EXAMPLE: 5-6 months 30 Weight Watcher’s 2012

EXAMPLE: Dr. Judy 2018 2 months 5-10 Medical Center Diet Pills TX

Use the information below to help you remember diets followed in the past 5 years so you can more easily complete the “History of Weight Loss Method’s” form on the previous page. Commercial Programs Popular Diets or Fad Diets Diet Center Blood Type Diet Diet Workshop Body for Life Jenny Craig Cabbage Soup Diet LA Weight Loss Calorie Counting NutriSystems Carbohydrates Addicts Diet Overeaters Anonymous (OA) Dr. Phil’s Ultimate Weight Loss Physician’s Weight Loss Center Eat More, Weigh Less (Dr. Ornish) Take Off Pounds Sensibly (TOPS) eDiets.com Weight Watchers Glycemic Index Grapefruit Prescription Diet Medications Hollywood Amphetamines Low Carb (i.e. Atkins) Meridia (sibutramine) Low Fat Mayo Clinic Diet Phentermine (Fastin/Adipex/Ionamin) Protein Power Xenical (orlistat) Richard Simmons South Beach Liquid Diets Sugar Buster’s Carefast The Zone Formula 3 Volumetrics HMR Medifast Therapy and Other New Direction Programs/Diets Optifast Acupuncture Slimfast Behavior Therapy Diabetic Diet Herbal and Exercise Programs Non-Prescription Remedies Fasting Alli Hypnosis Dexatrim Inpatient psychiatric program Ephedra (ma huang) Previous weight loss surgery Hydroxcut Previous gastric stapling Laxatives Psychotherapy Metabolife Registered Dietitian

NAME: DATE:

Over the last 2 weeks, how often have you been bothered by any of the following problems? More than Several Nearly (use "ⁿ" to indicate your answer) Not at all half the days every day days

1. Little interest or pleasure in doing things 0 1 2 3

0 1 2 3 2. Feeling down, depressed, or hopeless

0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much

0 1 2 3 4. Feeling tired or having little energy

0 1 2 3 5. Poor appetite or overeating

6. Feeling bad about yourself or that you are a failure or 0 1 2 3 have let yourself or your family down

7. Trouble concentrating on things, such as reading the 0 1 2 3 newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or 0 1 2 3 restless that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead, or of 0 1 2 3 hurting yourself

add columns + +

(Healthcare professional: For interpretation of TOTAL, TOTAL: please refer to accompanying scoring card).

10. If you checked off any problems, how difficult Not difficult at all

have these problems made it for you to do Somewhat difficult your work, take care of things at home, or get Very difficult along with other people? Extremely difficult

This waiver is to inform you that you will have an appointment with a registered dietitian today in our office. This appointment will be coded and billed as "medical nutrition therapy" only. It will be your responsibility to verify that your insurance covers this type of service. It is important to know that the coding of this service will not be altered once performed.

Please be aware that insurance may not pay for all of your healthcare costs. Some items and services are considered “non-covered benefits” under your health insurance plan and, your insurance may not pay for these services. By signing below you acknowledge that every billing effort will be made to your insurer for the reimbursement of medical nutrition therapy. In the event that your insurance does not pay, then you agree to be responsible for the balance.

I acknowledge that I have been informed in advance of receiving these services, and that these services may not be covered by my health insurance plan. I have chosen to receive these services and understand that I will be financially responsible for the charges and any remaining balance, in the event my insurance company does not make payment.

Print Patient Name: ______

______Patient Signature Date