BARIATRIC CONSULTATION

PATIENT INFORMATION

Patient’s Last Name First Middle Initial Mr. Miss

Mrs. Ms.

Birth Date Age Gender: Male Female Other Marital Status: Married Single

Hispanic or Latino Ethnicity: Yes No Language: English Other: Widowed Divorced

Race: American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Asian Black or African American White

Social Security Number E-mail

Street Address Apt# City State Zip Code

Home Phone Cell Phone Work Phone

Occupation Employer Employer Phone No.

In Case of Emergency, Contact Relationship Emergency Contact Number

Referring Provider (Full Name) Phone No.

Primary Care Provider (Full Name) Phone No.

Preferred Pharmacy Name Phone No.

How did you hear about us?: Family/Friend Physician Referral Website: Other:

INSURANCE INFORMATION

Primary Insurance Member ID# Group ID#

Subscriber’s Name Relationship DOB

Subscriber’s Social Security #

Secondary Insurance Member ID# Group ID#

Subscriber’s Name Relationship DOB

Subscriber’s Social Security #

By signing here, I attest that the above information is true and accurate to the best of my knowledge.

Patient/Guardian signature Date BARIATRIC CONSULTATION

NUTRITION HISTORY

How many meals do you eat daily? Do you snack between meals Yes No

Do you drink soda Yes No Regular soda Yes No Diet soda Yes No How many sodas do you drink daily?

FOOD PREFERENCES

Candy Yes No Fast Food Yes No

Cookies Yes No Seafood Yes No

Fried Food Yes No Cakes or pies Yes No

Pizza Yes No Vegetables Yes No

Chocolate Yes No Steak or red meat Yes No

Chips & snacks Yes No Dairy products Yes No

FOOD ALLERGIES

Please list any food allergy you have:

FOOD PATTERNS

Please record the type of food and the amount you have eaten over the past two days: All foods eaten yesterday All foods eaten the day before yesterday Before breakfast

Breakfast

Morning break

Lunch

Afternoon snack

Dinner

After dinner

Before bed

Other BARIATRIC CONSULTATION

WEIGHT LOSS HISTORY

How tall are you? How much do you currently weight?

What was your best weight loss with dieting? What is your goal weight?

PRIOR WEIGHTS

List maximum weight for each of the past 5-6 years:

Year 20 Lbs. Year 20 Lbs.

Year 20 Lbs. Year 20 Lbs.

Year 20 Lbs. Year 20 Lbs. Many insurance companies require documentation of weight for 3-5 years. Please have your primary care physician fax records that document your weight over that time.

NON-SUPERVISED WEIGHT LOSS ATTEMPTS

Body For Life/Bill Phillips Low carbohydrate Atkins Diet Scarsdale Diet

Gloria Marshall Low fat AYDS Stillman Diet

Health spa Calorie counting Mayo Clinic Diet Sugar Busters

High protein Gym membership Pritikin Slim Fast

Hypnosis Home gym equipment Richard Simmons South Beach Diet Other (List):

SUPERVISED WEIGHT LOSS ATTEMPTS

Diet Pills From MD Nutri-System National Weight Loss Exercise Counseling

Diet Shots From MD T.O.P.S. Acupuncture Medifast

Diet Center Jenny Craig Weigh Of Life Metrical

Overeaters Anonymous New Direction Weight Watchers Nutritional counseling

Optifast Health Management LA Weight Loss Personal Trainer Resources

Supervised Calorie Psychological Other (List): Counting Counseling

WEIGHT LOSS MEDICATIONS

Acutrim Didrex National Weight Loss Exercise Counseling

Adipex-P Fastin Acupuncture Medifast

Alli Fenfluramine Weigh Of Life Metrical

Amphetamines Herbal Remedies Pritikin Nutritional counseling

Anorex New Direction LA Weight Loss Personal Trainer

Benzphetamine Health Management Supervised Calorie Psychological

Dexatrim BARIATRIC CONSULTATION

MEDICAL HISTORY Please check and explain any of the items below.

CARDIOVASCULAR

High Blood Pressure

Previous heart attack Chest pain or tightness

Heart failure

Rheumatic fever

Heart valve problems

Shortness of Breath

High Cholesterol

High Triglycerides

DIABETES AND ENDOCRINE SYSTEM

Diabetes Mellitus None Type I Type II When was your diabetes first diagnosed?

How long have you been taking Oral agents? Yes No Insulin? Yes No

Does your diabetes resolve with weight loss? Yes No

How often do you test your blood sugar at home?

What are your usual blood sugars? Give a range:

Pre-diabetic (Abnormal glucose tolerance test) Yes No Have you had Gestational Diabetes? Yes No

Thyroid Problems Yes No Type:

GASTROINTESTINAL

GALLBLADDER

Do you have gallstones? Yes No Have you had your gallbladder removed? Yes No

GALLBLADDER

Stomach Ulcers Yes No Gastritis? Yes No

Have you previously taken medicine for ulcers or gastritis? Yes No

Heartburn? Yes No How Often? Daily Occasionally Rarely

Do you take medications for heartburn? Yes No Which one:

Have you had an upper endoscopy? Yes No When:

COLON

Frequent Diarrhea Yes No Frequent constipation Yes No Crohn’s disease or Ulcerative Colitis Yes No

Have you had a colonoscopy? Yes No When:

LIVER

Hepatitis Yes No Type: Cirrhosis Yes No BARIATRIC CONSULTATION

MEDICAL HISTORY Please check and explain any of the items below.

RESPIRATORY

Asthma Last Attack?

Emphysema or COPD

Bronchitis Number of times in the past 2 years?

Pneumonia

Problems with anesthesia What Type?

Blood clots in legs Blood clots in legs Lymphedema

Family history of blood clots Who in the family?

SLEEP APNEA

Have you been diagnosed with Sleep Apnea? Yes No

Have you previously had a sleep study? Yes No

Do you use CPAP or BIPAP? Yes No

If you answered “No” to the above, answer the following questions:

Do you snore? Yes No

Have you been told that you hold your breath or stop breathing during sleep? Yes No

Do you wake up gasping for breath? Yes No

Do you awaken with headaches? Yes No

Do you fall asleep frequently while reading? Yes No

Have you fallen asleep while driving or stopped at a light? Yes No

Do you have jerking movements while sleeping? Yes No

Do you often wake up with a dry mouth or sore throat? Yes No

Do you still feel exhausted after 8 hours of sleep? Yes No

MUSCULOSKELETAL

Hip Pain Mild Moderate Severe

Knee Pain Mild Moderate Severe

Ankle Pain Mild Moderate Severe

Foot Pain Mild Moderate Severe

Back Pain Mild Moderate Severe

Neck Pain Mild Moderate Severe

Are you using anti-inflammatory medications? Yes No

Are you using narcotic pain medications? Yes No BARIATRIC CONSULTATION

MEDICAL HISTORY Please check and explain any of the items below. KIDNEY AND BLADDER

Do you spill urine when coughing or sneezing? Yes No

Have you had bladder infections? Yes No Have you had kidney infections? Yes No

Have you had kidney stones? Yes No

NEURO-PSYCHIATRIC

Depression Yes No Is your depression due to obesity? Yes No

Have you been in counseling? Yes No

Seizures Yes No Severe Headaches Yes No

Visual problems Yes No Type:

Eating Disorders: None Bulimia Anorexia Nervosa Other

OTHER

Do you bleed or bruise easily? Yes No Have you ever had a blood transfusion? Yes No

Do you have swelling of your legs or feet? Yes No Do you have varicose veins? Yes No

Do you have ulcers of the legs? Yes No Do you have HIV or AIDS? Yes No

FOR WOMEN

Have you had problems conceiving? Yes No Is your depression due to obesity? Yes No

How many pregnancies have you had? How many children do you have?

Any pain with your period? Yes No

Do you have Polycyctic Ovarian Syndrome? Yes No Type:

Are you on Birth Control? Yes No Method:

PRIOR SURGERIES Please list all the surgeries you had done and when you had them:

Surgery Year BARIATRIC CONSULTATION

FAMILY HISTORY Please check illnesses that have occurred in any of your blood relatives and indicate which relative:

Condition Relatives

Obesity

Diabetes

Heart Disease

High Blood Pressure Cancer (specify type) Arthritis

Early death (specify cause)

SOCIAL HISTORY

Tobacco use: Never Now Past How many per day? No. of years? When did you quit?

Recreational Drug Use: Never Now Past How many per day? No. of years? When did you quit?

Alcohol Consumption: Never Now Past How many per day? No. of years? When did you quit?

MEDICATIONS Please list all current medications. Please include dosage (mg) and frequency (once, twice per day, etc).

Medication Dosage (mg) Frequency BARIATRIC CONSULTATION

ALLERGIES

Have you ever had an allergic reaction to any medications? Yes No Please list all allergies and reactions to any medications.

Medication Reaction

Do you have a Latex allergy? Yes No Do you have an allergy to Iodine? Yes No

Do you have an allergy to Dye? Yes No Do you have an allergy to tape? Yes No

IMPACT OF OBESITY

Describe in your own words how obesity is affecting your life. Use a separate sheet if you need to. BARIATRIC CONSULTATION

PATIENT FINANCIAL RESPONSIBILITY FOR SERVICES

The providers and staff of The Virginia Hospital Center Physician Group are committed to providing you with the best possible care and to help you receive your maximum allowable insurance benefits. We are here to help and are happy to answer any questions you may have about billing for our services. While the filing of insurance claims for contracted insurance carriers is our obligation, all fees are ultimately your responsibility. We recommend that you be completely familiar with your individual coverage, benefits, limitations, and exclusions. All questions in this regard should be addressed to your insurance carrier directly.

Please be aware of the following important financial responsibilities:

• It is your responsibility to keep all insurance and demographic information up to date.

• You must make all co-payments at the time of your visit, as well as payments for any deductibles, co-insurance, or non-covered services.

• If referral is required for your visit, it is your sole responsibility to arrive for your appointment with your required referral. If you do not have the required referral at the time of your appointment, you will be required to pay the full appointment fee at the time of service.

• If you do not come to your appointment and have not cancelled or rescheduled, we will charge a No Show Fee of $40. If you cancel or reschedule an appointment with less than 24 hours notice prior to the scheduled appointment time, we will charge a Late Cancellation fee of $25.

• If you do not have insurance or receive treatment for a non-covered service, you must pay for services in full at the time of the visit. In most cases, we are able to give you a discount for payment given in full at the time of service.

• You may pay in the form of cash, money order, check and credit card in most cases. We will assess a fee of $30.00 for returned checks.

• If your account becomes delinquent, we will submit the account to our attorneys, at which time you will be responsible for all collection costs including attorney fees, court costs, and all civil penalties as provided by the Code of Virginia.

I hereby authorize Virginia Hospital Center Physician Group to apply for benefits for services rendered to me. I certify that the information that I have provided with regard to insurance coverage is correct. I further authorize the release of any necessary information, including medical information, for any related claim to my insurance carrier or to CMS (Centers for Medicare and Medicaid Services) and its agents in order to determine these benefits or benefits payable for related services. I request that payment of authorized benefits due under my insurance plan, including Medicare if applicable (assigned charges), be made payable directly to Virginia Hospital Center Physician Group or any individual provider, on my behalf.

In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. This assignment will remain in effect until revoked by me in writing.

I understand that I am financially responsible for the total charges for services rendered which may include non-covered services. I agree that all amounts are due upon request and are payable to Virginia Hospital Center Physician Group. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. I further understand should my account become delinquent; I shall pay the reasonable attorney fees or collection expenses of Virginia Hospital Center Physician Group.

I have read the above Patient Financial Responsibility for Services and have provided true and correct insurance and demographic information. I will promptly notify you of any changes to my health insurance carrier, including new ID #’s with my current carrier.

Signature of Patient Printed Name Date

Legal Representative Printed Name Date BARIATRIC CONSULTATION

CONSENT FOR TREATMENT

1. General Consent for treatment. I hereby authorize employees and agents of Virginia Hospital Center Physician Group and Virginia Hospital Center Urgent Care, including physicians, physician assistants, nurse practitioners, nursing and other staff members to render medical evaluations and care to the patient indicated below. I acknowledge that according to Virginia state law, I shall be deemed to have consented to the testing for infection with Human Immunodeficiency virus (HIV), Hepatitis B, Hepatitis C viruses should any healthcare provider, or any person employed by or under the direction and control of a healthcare provider, be directly exposed to my body fluids in connection with rendering care in a manner which may, according to the current guidelines of the Center for Disease Control, transmit HIV, Hepatitis B, or Hepatitis C viruses. Test results may be released to the person exposed. 2. E- Prescribing Consent. The Medicare Modernization Act (MMA) of 2003 lists standards that have to be included in an ePrescribe program. These include: • Formulary and benefit transactions — Gives the prescriber information about which drugs are covered by the drug benefit plan. • Medication history transactions — Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events. By signing this consent form you are agreeing that this office can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes. 3. Other Consents. Virginia Hospital Center participates in an affiliated teaching program; physicians may be assisted in patient care by residents and/ or medical students. I understand I have the right to refuse residents or medical students be involved in my care and will notify my care provider (s) of any such decision. I agree to receive a survey from a premier polling company. The surveys are used to assess the quality of care delivered to our patients and ensure that we are providing the best care possible. I have the right to refuse participation by notifying the registration representative 4. Patient Information. I authorize the practice to provide (Print Person’s Name/Relationship)______­ with information (including both medical and billing information). This release will remain active in your electronic health record, and will not be cancelled unless there is written authorization from the patient to do so on file. 5. Health Information Exchange. Virginia Hospital Center participates in HIE which is the transfer of healthcare information electronically across physician offices and affiliates to the Hospital. I understand that: my healthcare providers will access externally available electronic health records including medication history and medication prescribing information; the Hospital will transmit/receive electronic health information between affiliated physicians and organizations who are involved in my care using HIE.I understand that I may decide to opt out of participation at any time either in writing, or by completing the Virginia Hospotal Center Physician Group – Surgical Specialists Health Information opt-out form. 6. Patient Portal. Virginia Hospital Center Physician Group and Virginia Hospital Center Urgent Care utilize a web portal as part of the electronic health record, which communicates information including but not limited to test results and visit summaries. You may activate your patient portal by providing your physician’s office with a current email address and completing the user registration process through eClinical Works.I understand that I may decide to opt out of participation at any time either in writing, or by completing the Virginia Hospotal Center Physician Group – Surgical Specialists Health Information opt-out form. * The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing this consent, the patient will not be provided medical care except in the case of an emergency.

Signature of Patient Printed Name Date

Signature of Parent or Legal Guardian Relationship, if Guardian Date

Contact information If Minor: Family Address:

Guardian’s Telephone: Cell: Work: In the event we do contact you, is it suitable to leave a message(s) in the following manner (Check all that apply)

On answering machine With an ADULT household member Exclusively with patient

Provider Representative Signature/Witness Date