dear patient: - lifebridge health · web viewdear patient: thank you for ... carbohydrate diet...

LifeBridge Health Division of Bariatric & Minimally Invasive Surgery

5401 Old Court Rd.Randallstown, MD 21133

(410) 701-4880Dear Patient:

Thank you for inquiring about our weight loss surgery program! The decision to undergo weight loss surgery is not a decision you made quickly; in a similar fashion, the process of preparing you for surgery also cannot occur quickly, nor be rushed. Please take the time to fill out the enclosed intake form carefully and completely. Remember to attach a legible copy of your picture ID along with your medical insurance card (front & back). Our staff will then contact you to give you an appointment date, usually within two weeks of receipt of your application.

In the meantime, we encourage you to attend our informational seminars, which we hold at Sinai Hospital’s Zamoiski Auditorium and Northwest Hospital Pike Conference Room. We will be present at each seminar, as well as, members from our staff and post-op patients. Everyone is invited to attend, be sure to verify the dates on our website (http://www.lifebridgehealth.org/bariatricsurgery) or call 1-866-404-DOCS (3627).

Most insurance companies require that policy holders be seen monthly for 3-6 consecutive months to document weight loss attempts and progress. Therefore, as an insurance and program requirement, we require patients to see the Registered Dietitian at Sinai Hospital, Northwest Hospital, or Dorsey Hall location in Columbia. Adherence to the program greatly increases your success following bariatric surgery. All program locations adhere and teach the same nutritional information concerning food choices and surgery.

Prior to being seen at one of the LifeBridge Health centers, ask your Primary Care Physician (PCP) for a request for consultation. If a referral is required with your insurance plan, please make sure we have an updated referral on file. All co-payments are due at the time of service. PLEASE NOTE we only accept cash, Visa, and/or MasterCard for payment at Sinai and Northwest Hospital locations. We only accept cash or checks at our other locations.

Your insurance plan will likely require extensive testing to ensure that they will approve the surgery. If you prefer, you can obtain some of this BEFORE your initial consultation. The following are required by ALL insurance companies of all patients prior to scheduling surgery:1) Proof of attendance at a minimum of one of our bariatric seminars.2) A letter from your primary care physician. This letter should summarize your diet history, your obesity-related

medical problems and any physician-supervised weight loss attempts that you have had. It should also include a sentence or two stating that your physician feels that you are a good candidate to undergo surgery.

3) Psychology/psychiatry clearance: all patients are required to undergo a psychological evaluation prior to surgery, so that we can document adequate knowledge of the procedure, reasonable weight loss expectations, and the ability to comply with the rigorous dietary restrictions post-operatively. You can obtain clearance from your own psychologist or psychiatrist if you prefer.

Every patient will require additional pre-operative testing, but these tests will be ordered on an individual basis after you have met with one of the surgeons. If you have any questions about the Bariatric Surgery Program at Sinai Hospital, please contact us at 410 601-4486 and one of our staff will be glad to help you.

We look forward to meeting you and helping you reach your goal of a healthy weight and healthier lifestyle. Christina Li, MD, FACS Celine Richardson, MD, FACS

410-701-4880 (office) 410-701-4883 (fax)Web Site: Lifebridgehealth.org/bariatricsurgery E-mail: [email protected]

(updated on 09/30/16)

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mailto:[email protected]



(410) 701-4880

****KEEP THIS PAGE***AVOID these medications 2 weeks prior to surgery and call

the office before taking any new medication for pain management

Aspirin Products:AggrenoxAlka-SeltzerAnacinAscriptinAsperDrinkAspergumAspirin/Butalbital/CaffeineAspirin with buffersAspirtabAspir-TrinBayerBC PowderBismuth Subsalicylate (Pepto Bismol, Kaopectate, Bismatrol, Kola-Pectin, Diotame, Kapectolin, Bismate, Bismakote, Bismuth, Stomach Relief, Kao-Tin, Kensorb, Kao-Paverin, Peptic Relief, Sootheze).BufferinButalbitalCarisoprodol CompoundCitrated/Aspirin/caffeineCopeDamason-PEasprinFiorinal

Aspirin Products:Ecotrin Endodan EquagesicExcedrinGelprinGenacoteGoody’s HalfprinOrphenadrin P-A-C Magnesium SalicylateMagnaprinMicraininMiniprinNorgesic (Forte)Norwich AspirinPamprinPercodan RobaxisalSomaSt. Joseph’s AspirinSynalgos-DCTrilisateVanquishZorprin

Store brands: Good Neighbor Pharmacy, Good Sense, Leader, Medi-First, Quality Choice, Top Care, Rite Aid, etc.

NSAIDS products:Diclofenac (Flector, fcatafrlam, Voltaren, Arthrotec, Cataflam, Cambia)Disflunisal (Dolobid)Etodolac (Lodine)Fenoprofen (Nalfon)Flurbiprofen (Ansaid)Ibuprofen (Advil, Motrin, Genpril, Haltran, Menadol, Midol, Vicoprofen, Dristan)Indomethacin (Indocin)Ketoprofen (Oruvail, Orudis)Ketorolac (Toradol, Acular, Acuvail, Sprix)MeclofenamateMefenamic (Ponstel)Meloxicam (Mobic)Nabumetone (Relafen)Naproxen (Naprosyn, Prevacle Napra PAC, Aleve, Naprelan, Anaprox)Oxaprozin (Daypro)Piroxicam (Feldene)Salsalate (Disalcid, Amigesic, Salflex, Persistin, Mono-gesic, Marthritic, Arthra-G, Argesic-SA)Sulindac (Clinoril)Tolmetin (Tolectin)

Cox-2 InhibitorsCelecoxib (Celebrex)

****KEEP THIS PAGE***



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(410) 701-4880

Application Process1. Call your insurance company and complete the Insurance

Verification form on page 4.2. Complete the Patient Application on pages 5 - 15 and the

Nutritional Assessment on pages 16 – 22.3. Return the Insurance Verification, Patient Application, and the

Nutritional Assessment to our office (pages 4 – 18). a. Please keep the folder & resource papers in the right sleeve.

4. Our office staff will verify your insurance benefits.5. One of the physicians will review your application.6. Our office staff will call you to schedule an initial appointment

with the physician and dietitian.a. Reminder: the nutritional consultation has a mandatory

program fee (not covered by any insurance) which is due at the initial appointment.

b. All self-pay portions are due at the time of service.c. We accept only cash or credit cards as payment. We do not

accept checks.7. Please allow 1-2 weeks, plus mailing time for our staff to contact

you.8. While waiting to hear from our office you can complete the

following steps:a. Contact your Primary Care Physician for any necessary

referrals per your insurance requirement. (Some offices require 1-2 weeks notice to have referrals ready).

b. Attend one of our bariatric seminars (see enclosed flyer for dates).

PLEASE INCLUDE COPY OF DRIVER’S LICENSE AND INSURANCE CARD (FRONT & BACK) WITH APPLICATION!



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(410) 701-4880

Additional Information HMO'S, POINT OF SERVICE, AND MANAGED CARE PLANS:

If your insurance company is an HMO, point of service, or managed care plan, you must obtain a written out-of-network referral before your consult with the surgeon. You must follow the rules of your insurance company in order to obtain the highest level of benefits. Your primary care physician's office will need to contact the insurance company for a referral. You may make an appointment with the surgeon; however, the referral must be received or brought with you to the appointment.

SELF PAY PATIENTS: If your insurance does not cover gastric bypass surgery and you wish to proceed as a cash patient, please contact the office for fees and scheduling information.

PROGRAM FEE: A program fee is required at your initial appointment. This fee is non-refundable and covers 1 year of unlimited visits or consultations with the nutritionist.

PAIN MEDICINE : Do not take any “pain medication/anti-inflammatories” three weeks prior to surgery without consulting with your surgeon (see list on page 2). Most pain medicines increase the chance of bleeding. This may result in cancellation of your procedure.

IMPORTANT NOTICESWe only accept cash or credit card as acceptable

form of payment.

We require 24 hour notice if you are unable to keep your scheduled appointment. A fee of $25

will be billed to you for each missed appointment.

Insurance Verification FormCall to verify insurance coverage for bariatric surgery. The telephone number is located on the back of your insurance card. This completed form must be submitted with your application.



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(410) 701-4880

First Name:

Middle Initial:

Last Name:

Birth Date:

Insurance Company:Insurance Phone No.:

Date Insurance Company Called:_____________________Spoke with:__ ___________________

Type of Plan: HMO

POS

PPO MCO Medicare

Other: ________________

Policy No.: __________________Group No.: _______________

Effective Date: _____________

Ask your insurance representative the following questions:1. Is this a small group policy? Yes No2. Does this policy have ANY exclusion for Bariatric Surgery or

Morbid Obesity? Yes No3. Does the insurance cover the following procedures:

a. Gastric Bypass (CPT 43644)b. Gastric Banding (CPT 43770)c. Sleeve Gastrectomy (CPT 43843)

Yes No Yes No Yes No

4. Is this procedure subject to any pre-existing conditions on the policy? If yes, please list _______________________________________________________

Yes No

5. Are there specific criteria that need to be met in order to qualify for this surgery? If yes, please list:

a. Total months of consecutive supervised weight lossb. Other: __________________________________________

Yes No _____ months

5. Do you need a referral from your Primary Care Physician to see a Specialist? Yes No

6. Is there a co-pay to see the surgeon?a. What is the co-pay?

Yes No$ ___________

7. Do you have a deductible?a. What is the amount?b. How much of the deductible has been met?

Yes No$ ___________$ ___________

Please include a copy of your driver’s license and 410-701-4880 (office) 410-701-4883 (fax)

Web Site: Lifebridgehealth.org/bariatricsurgery E-mail: [email protected](updated on 09/30/16)

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(410) 701-4880

insurance card (front & back) with the application



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(410) 701-4880Patient Application

NAME: _________________________________ Date: __________________

I am interested in seeing:

I am interested in having:

What is your preferred location?

Dr. Christina Li Gastric Bypass Northwest Dr. Celine Richardson Laparoscopic Band Sinai

Sleeve Gastrectomy Ellicott City

Social Security No.:First Name: Middle

Initial:Last Name: Gender: M F Applicant’s Maiden Name:Birth Date: Current Age:

Weight: Height: BMI:

Mother's Maiden Name: ____________________________________________

Insurance Information:

Primary Insurance Secondary InsuranceInsurance Carrier Name:Group Number:ID Number:Policyholder’s Name:Policyholder’s DOB:Policyholder’s SS#:Relationship to Insured:Insurance Address:City, State, Zip:Phone Number:Fax Number:



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(410) 701-4880

NAME: _________________________________Contact Information:Home Address:City: State: Zip:E-mail:

May we contact you at this number?Home Number: Yes No Preferred Cell Number: Yes No Preferred Work Number: Yes No Preferred Employed: Yes No Full Time Part Time Employer: Occupation:Employers Address: Length of time @ current employment: ________ Years ________ Months

Emergency Contact Information:

Name: Relationship:

Home Address:City, State, Zip:

Home Number: Cell Number : Work Number:Pharmacy Information:

Pharmacy Name: ______________________ Phone Number: ________________________

Location: ______________________________ Fax Number: ___________________________

Family/Friend Insurance Internet

Magazine Newspaper Primary Care Physician

TV Other: ________________



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(410) 701-4880I heard about LifeBridge Health Bariatric through:NAME: ________________________________

Primary Care Physician Other PhysicianName:Specialty:Address:Address 2:City:State:Zip:Phone Number:Fax Number:

Physician Information:

Social History:Marital Status: Single Married Divorced Separated Widowed

Ethnic Origin: Black/African American Hispanic White/Caucasian Asian/Oriental Other:

Education: 9 to 11 years High School

Graduate Vocational/Technical Attended College College Graduate Post Graduate

Degree

Number of Children: None 1 2 3 4 5 or more

Religion: Atheist Catholic Jehovah Witness Jewish Presbyterian Other:

Do you currently or have you ever use/d tobacco products? If yes, what kind: Cigarettes Cigars Chewing tobacco

Yes No If yes, how much: 1/2 pack or less per day Between 1 – 1.5 packs per day Between 1.5 – 2 packs per day 2 packs or more per day

Do you drink alcohol? Yes If yes, how much: Less than 2 per day Between 2 – 5 per day Between 6 – 10 per day

No If yes, how often: Daily Weekly Monthly

Do you use illegal drugs? Yes If yes, what kind: Marijuana Cocaine Heroin

No If yes, how often: Daily Weekly Monthly



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(410) 701-4880 More than 11 per day Occasionally Amphetamines Occasionally

List the diets/programs have you tried within the last 5 years:Diet or Weight Loss Medication

Year Length in Months

Number of Pounds Lost

What age were you considered obese?What was your lowest adult weight?What is your desired weight?

Check if you have used the following medications to lose weight: Phentermine Phen-Fen

Orlistat (Xenical) Meridia

B-12 shots Other

Check the eating behaviors which have contributed to weight gain: Skipped meals Frequent sweets Vomiting after large meals Large portions High carbohydrate diet Frequent snacking Fatty foods Binge eating Fast foods Emotional eating Laxative use Other:



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(410) 701-4880

NAME: _________________________________

Drug Allergies: Check if no allergiesMedication Allergies Type of reaction

Current medication (prescription and non-prescription): Check if no medications

Medication Strength Frequency Purpose

Started(Initials /Date)

Stopped (Initials /Date)



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(410) 701-4880NAME: _________________________________

Medical History (all that apply): Anxiety DVT (Leg Blood Clots) Peripheral Edema

(Swelling of the legs) Arthritis Fibromyalgia Pneumonia

Asthma Heart Attack Pulmonary Embolism

Bronchitis High blood pressure Reflux Disease(Heartburn or severe indigestion)

Cancer Hypercholesterolemia(High cholesterol) Seizure

Cardiac Surgery Hypertriglyceridemia (High triglycerides)

Sleep ApneaDiagnosed Observed

Chest Pain Hyperthyroidism Snore

CHF Hypothyroidism Stress Incontinence

Depression Leg Ulcers Stroke Diabetes Type I (Insulin dependent) Lower back pain Varicose Veins Diabetes Type II (Non-

Insulin Dependent) Migraines/Headache Other:

Surgical History (all that apply): r Check if no surgical historySurgery Date Comment C section Number:

Gall Bladder Open Laparoscopic

Hernia Hiatal Inguinal Incisional

Umbilical

Hysterectomy Abdominal Vaginal

Obesity - previous Band Gastric By-

pass Sleeve

Orthopedic Type: Tubal Ligation Other (list surgeries and year) : Hospital Admissions:



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(410) 701-4880NAME: _________________________________

Family History:Alive Age

(Current or at death)

Health Problems

Mother Yes No

Heart Disease Diabetes Blood clots Other:

Stroke Cancer Overweight/

obese

Father Yes No



obese

Maternal Grandmother

Yes No



obese

Maternal Grandfather

Yes No



obese

Fraternal Grandmother

Yes No



obese

Fraternal Grandfather

Yes No



obese

Sibling Brother Sister

Yes No



obese

Sibling Brother Sister

Yes No



obese

Sibling Yes Heart Disease Stroke410-701-4880 (office) 410-701-4883 (fax)

Web Site: Lifebridgehealth.org/bariatricsurgery E-mail: [email protected](updated on 09/30/16)

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(410) 701-4880 Brother Sister

No Diabetes Blood clots Other:

Cancer Overweight/

obese

HEAD AND NECK N/A

Change in vision Ringing in ears Nosebleeds Double vision Dizziness Hoarseness Deafness Sinusitis Other

CARDIOVASCULAR N/A

Palpitation Leg pain w/ walking High cholesterol Chest Pain Heart disease

Other Shortness of breath History of heart attack

RESPIRATORY N/A

Cough Asthma/Bronchitis Shortness of Breath

Wheezing Sleep ApneaDiagnosed Observed Other

GASTROINTESTINAL N/A

Loss of appetite Abdominal pain Changes in bowel habits

Difficulty w/ swallowing Vomiting History of blood

transfusion Nausea Bloody Stools History of polyps Belching/ Excess

Gas Jaundice Other

URINARY N/A

Difficulty urinating Stress incontinence Other

Urinating at night Kidney stones

ORTHOPEDICS N/A

Back pain Itching Seizures Arthritis Change in hair Difficulty walking History of fractures Weakness

Other Body Aches Numbness or tingling

PSYCHIATRIC N/A

Panic attacks Sleeping difficulties Bipolar disorder Chronic depression Attempted suicide Other

ENDOCRINE N/A

Thyroid Problems Hair Loss Other

Menstrual Problem DiabetesInsulin Non-Insulin

HEMATOLOGY N/A

Anemia Enlarged lymph nodes Other

Bleeding History of cancer



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(410) 701-4880ALLERGIES N/A Eczema Hay fever Asthma

NAME: _________________________________Health History (all that apply):

Nutritional AssessmentNAME: _________________________________

Complete the following questions. Please fill out as honestly and as with much detail as possible. Turn this in with your application.

Please list any food or drink with calories you have consumed in the past 24 hours:

Meal Time Place What & how muchBreakfast

Snack

Lunch

Snack

Dinner

Snack

1. What kinds of beverages do you drink and how much? How often?

How often per day/week How much (ounces)Regular Coffee/TeaDecaf Coffee/TeaRegular SodaDiet SodaJuice



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(410) 701-4880Other drinks with Sugar

2. How many meals do you eat away from home on weekdays?Breakfast _____________ Lunch_____________ Dinner_____________

3. How many meals do you eat away from home on the weekends?

Breakfast _____________ Lunch_____________ Dinner_____________

4. Do you currently take vitamins or minerals? □ Yes □ No If yes, list the names and amount you take:_____________________________________________________________

5. Do you have any food allergies □ Yes □ No If yes, which foods and type of allergic reaction?_________________________________________________________________

6. Do you have any food intolerance? □ Yes □ No If yes, please circle which food causes intolerance? Lactose Spicy Acidic Caffeine MSG Sugar Substitute Other_____________________________________________________________________________

7. Do you use sugar substitutes? □ Yes □ No If yes, which one?_________________

8. What do you do for a living and how many hours do you work per week?_________

9. Do you travel for your career? □ Yes □ No If yes, how often?________________



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(410) 701-4880

10. Marital Status: □ Single □ Married □ Divorce Number of children?________

11. Who prepares the meals in your home?________________________________________

12. Who does the grocery shopping?______________________________________________

13. Are there any religious, ethnic, or cultural factors affecting food choice? □ Yes □ No If yes, please elaborate__________________________________________________

14. Are the meals cooked in the home low far? □ All the time □ Sometimes □ Never

15. Do you eat fried, stir fried, or sautéed foods cooked at home? □ Yes □ No If yes, how often and which type?___________________________________________________

16. What kind of fats do you use for frying and sautéing at home? □ Butter

□ Margarine □ Olive Oil □ PAM type spray □ Shortening or Lard

□ Other:________________________________________________________________________

17. What kind of spreads do you use for bread? □ Reduced calorie margarine

□ Maragrine □ Butter □ Other:_______________________________________________18. What is the food/drink that you will have the hardest time giving up? _______________________________________________________________________________________19. Describe frequent cravings_______________________________________________________________________________________________________________________________________________



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(410) 701-4880

20. Do you wake up in the middle of the night hungry? □ Yes □ No If yes, how often?____________________________________________________________________________

21. Do you remember what you eat? □ Always □ Sometimes □ Never

22. List the restaurants where you often eat:____________________________________________________________________________________________________________________________________________________________________________________________________________

23. Do you eat when you are? □ Bored □ Happy □ Sad □ Stressed

24. Do you ever binge on food until you are uncomfortable or ill? □ Yes □ No If yes, how often?___________________________________________________________________

25. Do you drink alcohol? □ Yes □ No If yes, how many at a time and how often? ___________________________________________________________________________

26. Do you smoke? □ Yes □ No If yes, how many cigarettes a day?_____________

27. Do you exercise now? □ Yes □ No If yes, what exercise do you do and how often do you exercise?____________________________________________________________28. Is there any reason why you cannot exercise or should not exercise?_________________________________________________________________________

29. Has your weight changed in the past year? □ Yes □ No If so, how much have you gain or lost? ____________________________________________________________



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(410) 701-4880

30. What do you think is a realistic weight for you?__________________________________

List the diets/programs you have tried in the last 5 years: diet or weight loss medication

Year Length in Months Number of Pounds Lost

31. Have you had a previous weight loss surgery? □ Yes □ No If yes, list the date the surgery was performed, which procedure was done, and where the procedure was performed.________________________________________________________

32. What kind of education were you given with the previous weight loss surgery?____________________________________________________________________________________________________________________________________________________________________

33. Do you use any meal replacement products (liquids, bars, protein shakes)? □ Yes

□ No If yes, how often and which one?________________________________________

34. Do you use any other dietary supplements on a regular basis? □ Yes □ No

□ Black Kohash □ DHEA □ Fiber powders/tablets □ Fish or Flaxseed oil



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(410) 701-4880

□ Garlic pills □ Glucosamine Chondrontin □ Herbs □ PremarinAmounts:___________________________________________________________________________________________________________________________________________________________

35. Have you had any history with eating disorders? Such as binge eating and then

vomiting or not eating or eating very little for long periods of time. □ Yes □ No If yes, please be specific on age/type of eating disorder/year disorder occurred/duration of disorder and circumstances that were contributing to the issue.. If you were professionally treated, how long ago was the treatment and did you receive clearance from your doctor?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 36. Do you have any special needs for education material?□ Reading problems □ Deafness □ Poor eyesight □ Other_________________

Welcome to the program I look forward to meeting with you! Kim Visioni RD, LDN 410-701-4881 (office) 410-701-4883 (Fax) [email protected]



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dear patient: - lifebridge health · web viewdear patient: thank you for ... carbohydrate diet...

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