Patient Demographics

Name: _________________________________Address: _______________________________ ________________________________ ________________________________ City State Zip County

Marital Status: ____________________________Spouse’s Name: __________________________

DOB: ______________Age:_______ Sex: M FHome Phone: ____________________________ Work Phone: _____________________________Cell Phone: ______________________________Email: __________________________________ Social Security #: _________________________May we contact your spouse? Y N

Emergency Contacts: ________________________________________________________________________ Name Relationship Phone Alternate Phone

________________________________________________________________________ Name Relationship Phone Alternate Phone

Are you employed? Y NFull Time Part Time Student Homemaker Retired Self Employed

Medical History

Insurance InformationEmployer Name: __________________________

Address: ________________________________ ________________________________ ________________________________ ________________________________ City State Zip County

Policy Holder Name: _______________________

Occupation: _____________________________

Policy Effective Date: ______________________Customer Service #:_______________________Policy or ID #: ____________________________ ________________________________

Relationship to Patient:_____________________

Primary Insurance Carrier: _____________________________________________________________

Address: ________________________________ ________________________________ ________________________________ ________________________________ City State Zip County

Policy Holder Name: _______________________

Policy Effective Date: ______________________Customer Service #:_______________________Policy or ID #: ____________________________ ________________________________

Relationship to Patient:_____________________

Secondary Insurance Carrier: _____________________________________________________________

1Updated 06.28.10

Who is your current employer? __________________________________________________________

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Weight History

Current Weight ____________ Max Weight _____________ Lowest Adult Weight ____________Height: __________________ Date of Max Wt: __________ Date of Lowest Weight: __________BMI: ____________________

How would you describe your current weight? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________

At what weight have you felt your best or think you would feel your best? ______________________________

How does your weight affect your daily activities? ________________________________________________________________________________________________________________________________________

Why do you want to lose weight? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Why are you considering surgery to help you lose weight? _________________________________________________________________________________________________________________________________________________________________________________________________________________________

How do you think your life would change if you reach your weight goal? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Age when you first began dieting? ____________Age when you first remember being overweight? _________

Medications Prescribed by a Phsyician for Weight LossMedications may be listed as both generic and name brand. Check the one prescribed to you.

AcutrimAdipiex-PAnorexDexatrimDexfenfluramineDidrexFastinFenfluramineIonaminMazanorMeridia

Stacker 2CoritslimEphedrineRelacoreOther _______________________ _______________________ _______________________

ObalanOrlistatPhenterminePhentrolPondiminReduxSanorexTepanolTopamaxTenuateXenical

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Weight Loss History

Most insurance companies require documented evidence of previous weight loss attempts, so it is very important that you complete this in detail.

Method Ages# of Times

TiredWeight

LostComments/Weight Regain

Weight WatchersTOPSFirst PlaceNutri-SystemJenny CraigLA Weight LossRichard SimmonsOvereaters AnonymousHerbal LifeDietitianSlim FastLiquid DietCabbage Soup DietMayo Clinic DietScarsdale DietAtkinsSouth Beach DietSugar BusterHigh Carbohydrate, Low FatStarvationBehavior ModificationPsychotherapyHypnosisSurgeryDiet BooksCalorie CountingDr. VitkinsDr. JagiellaDr. MartinExerciseOther (Please Describe)

Please enclose any documentation confirming your weight loss efforts.

Medical History

Have you ever had any of the following medical problems? (Choose one in each box that applies)

Hypertension (High Blood Pressure)

No personal historyBorderline, no medicationDiagnosis of hypertension, no medicationTreatment with single medicationTreatment with multiple medicationsPoorly controlled by medication, organ damage

Congestive Heart Failure No personal history or symptoms of congestive heart failureSymptoms with more than one ordinary activitySymptoms with ordinary activitySymptoms with minimal activitySymptoms at rest

Ischemic Heart Disease

Chest Pain

Peripheral Vascular Disease

No history of ischemic heart diseaseAbnormal ECG, no active ischemiaHistory of heart attack or take medications to prevent itHad surgeries or stents for heart attackActive ischemia

No symptoms of peripheral vascular diseaseCramping pain and weakness in the legs with medicationTransient ischemic attack (ie TIA or mini-stroke)Procedure for peripheral vascular diseaseStroke, loss of tissue secondary to ischemia

No chest pain symptoms/anginaChest pain with extreme exertion (running, swimming, etc.)Chest pain occurs with moderate activity or exertionChest pain occurs with minimal exertion (walking across room) or “at rest”Unstable chest pain/agina

(Coronary Artery Disease, Ischemic means that the heart is not getting enough blood and oxygen)

(A disease of the blood vessels characterized by narrowing and hardening of the arteries)

Lower Extremity Edema (swelling)

No symptoms of lower extremity edemaIntermittent lower extremity edema, not requiring treatmentSymptoms requiring treatment, diuretics, elevation or hoseStasis ulcersDisability, decreased function, hospitalization

DVT/PE (Deep Vein Thrombosis/Pulmanary Embolism)

No history of DVT/PEHistory of DVT resolved with medicationRecurrent DVT long term medicationPrevious pulmonary embolismRecurrnent pulmonary embolism, decrease function, hospitalizationVena Cava filter placed

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Glucose Metabolism No symptoms or evidence of diabetesElevated fasting glucoseDiabetes, controlled with oral medicationDiabetes, controlled with insulinDiabetes, controlled with insulin and oral medicationDiabetes, with severe complications (blindness, retinopathy)

Abnormal Lipids (such as high cholesterol, high bad cholesterol)

Not presentPresent, no treatment requiredControlled with lifestyle changeControlled with single medicationsControlled with multiple medicationsNot controlled

Gout/Hyperuricemia

Obstructive Sleep Apnea Syndrome

Obesity Hypoventilation Syndrome

No symptoms of gout/hyperuricemiaHyperuricemia, no symtomsHyperuricemia, medicationsJoint disease due to goutDestructive jointsDisability , unable to walk

No symptoms of obesity SOB (shortness of breath)Lack of oxygen on room airSevere SOBPulmonary HypertensionRight Heart Failure

No symptoms or evidence of sleep apneaSleep apnea symptoms (negative sleep study or not done)Sleep apnea diagnosis by sleep study (no oral appliance)Sleep apnea requiring oral appliance such as CPAPSleep Apnea with significant hypoxia or oxygen dependentSleep apnea with complications (pulmonary hypertension)

(excess uric acid in the blood)

Pulmonary Hypertension No symptoms or indication of pulmonary hypertensionSymptoms associated with PH (tiredness, OSB, dizziness, fainting)Confirmed Pulmonary Hypertension diagnosisWell controlled on anticoagulants and/or calcium channel blockerStronger medications and/or oxygen

Asthma No symptoms of asthmaIntermittent mild symptoms, no medicationSymptoms controlled with oral inhaler (such as albuterol)Well controlled with ongoing daily medicationSymptoms not well controlled with medicationHospitalized within last 2 years or history of intubation

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GERD No history of GERDIntermittent or variable symptoms, no medicaitonIntermittent medicationTake prescribed medication (H2 blocker or low dose PPI)Take high dose medicationMeet criteria for antireflux surgery, or prior surgery for GERD)

Liver Disease No history of liver diseaseMild enlargement of the liver, normal liver function test, fatty changeModest hepatomegaly, LFT alteration, fatty changeModerate to marked hepatomegaly, fatty changeMild inflammation, mild fibrosisDefinite NASH (nonalcoholic steatohepatits), cirrhosis, hepatic dysfunction by LFT’sHepatic failure, transplant indicated or done

Back Pain

Musculoskeletal Disease

Fibromyalgia

Polycystic Ovarian Syndrome(PCOS)

No symptoms of back painIntermittent symptoms not requiring treatmentSymptoms requiring non narcotic treatmentDegenerative changes or positive objective findings, symptoms requiring narcotic treatmentSurgical intervention done or recommended pending weight lossFailed previous surgical intervention with existing symptomsNo symptoms of musculoskeletal diseasePain with community ambulationNon narcotic pain medication requiredPain with household ambulation Surgical intervention requiredAwaiting or past joint replacement or other disability

(problems with muscle and bone such as joint disease)

No history of fibromyalgiaTreatment with exerciseTreatment with non narcotic medicationTreatment with narcoticsTreatment with narcotics; surgical intervention done or recommendedDisabling, treatment not effectiveNo history of polycystic ovarian syndromeSymptoms of PCOS, no treatmentTake birth control pillsTake Metformin (Glucophage) or TZD (thiazolidinedione)Combination therapyInfertility

(chronic disorder with widespread pain, tenderness, and stiffness of muscles)

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Psychosocial Impairment

Depression

Confirmed Mental Health Diagnosis

Stress Urinary Incontinence

Pseudotumor Cerebri

No impairmentMild impairment in psychosocial functioning but able to perform all primary tasksModerate impairment in psychosocial functioning and unable to perform some primary tasksSevere impairment in psychosocial functioning and unable to perform most primary tasksSevere impairment in psychosocial functioning and unable to functionNo symptoms of depressionMild and episodic not requiring treatmentModerate accompanied by some impairment, may require treatmentModerate with significant impairment, treatment indicatedSevere, definitely requiring intensive treatmentSevere requiring hospitalizationNoneBipolar DisorderAnxiety/Panic DisorderPersonality DisorderPsychosis

(leaky urine when you laugh, cough, or sneeze)

No history of stress urinary incontinenceMinimal and intermittentFrequent but not severeDaily occurence, requires sanitary padDisablingOperation ineffective

(benign intracranial hypertension. An abnormal condition such as headaches with dizziness, nausea, and/or pain behind the eyes)

No symptoms of pseudotumor cerebriHeadaches with dizziness, nausea, and/or pain behind the eyes, no visual symptomsHeadaches with visual symptoms and/or controlled with diureticsPatient has had MRI to confirm PTC, is well controlled with oral diureticsPatient is well controlled with stronger medicationsPatient requires narcotics or has had (or needs) surgical intervention

List all additional medical illness:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List all surgeries you have had:

Surgery Date Open or Laparoscopic

List allergies to any medication and include type of reaction and date of allergy:Penicillin IodineLatex

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medications:

Medication Dose & Frequency Condition

example: Prilosec OTC 30mg once a day Heartburn

Please enclose an additional sheet if necessary to list ALL medications

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Do you CURRENTLY have a problem with any of the following?

Social HistoryDo you use tobacco currently? __________How many years have you smoked? _____

Sleep History

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FeverNight SweatsLethargyLoss of AppetiteDizzinessHeadacheChange in visionHearingSinusesNose BleedsChronic CoughShortness of breathWheezing

PregnancyLast period: __________BreastTrouble walkingWeakness in arms/legsNumbness/tinglingJoint painSwellingInfectionAnxietySadnessFear

SnoringPalpitationsBleedingNauseaVomittingDifficulty swallowingBloatingDiarrheaConstipationBloody StoolChange in stoolUrinationKidneys

Did you smoke in the past? ____________How many years did you smoke? _______

Do you use any recreational drugs? __________________ Which ones? _______________________Have you ever had an addiction to drugs? _____________ _______________________

How many pack/day? _________________Have you tried to quit? ________________

How many pack/day? _________________Have you tried to quit? ________________

How likely are you to doze off or fall asleep in the following situations? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Please fill out the box below.

0= would never doze 2= moderate change of dozing1= slight change of dozing 3= high chance of dozing

0 1 2 3Sitting and Reading

Watching TV

Sitting, inactive in a public place (a theater or in a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch without alcohol

In a car, while stopped for a few minutes in traffic (at a traffic light)

Family History

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Mother Father Sibling Aunt/Uncle Grandparent

Obesity

Diabetes

Heart Disease

High Blood Pressure

High Cholesterol

Cancer

Arthritis

Early Death (Cause)

Physicians

Please list all physicians that are currently or recently caring for you:

Primary Care __________________________________________________________________________Physician __________________________________________________________________________ __________________________________________________________________________

Gynecologist __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

Pulmonologist __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

Psychiatrist/ __________________________________________________________________________Psychologist __________________________________________________________________________ __________________________________________________________________________

Orthopedic __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

Other __________________________________________________________________________ __________________________________________________________________________

Referring Physician

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Referring Physician: _____________________________ Phone Number: _____________________Address: ______________________________________ Fax Number: _______________________ ______________________________________ ______________________________________

How did you hear about the Floyd Center for Bariatric Services? __________________________________________________________________________________________________________________________________________________________________

Procedure Preference

Which surgical procedure are you currently most interested in?

Gastric Bypass Realize BandLap-Band Sleeve Gastrectomy No Preference