American Society of Bariatric Surgery. You can also find my educational and training background on our website:

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1 James A. Harris, MD, FACS Gastrintestinal and Laparscpic Surgery 1411 Physicians Drive Wilmingtn, NC Phne: (910) Fax: (910) Thank yu fr chsing Castal Surgery Specialists in yur pursuit f weight lss surgery. Weight lss surgery (bariatric surgery) can be a highly successful and rewarding treatment fr besity and its assciated medical diseases. Please read this intrductin carefully. Als, please fill ut the enclsed questinnaire as cmpletely as pssible and mail it back t ur ffice. Castal Surgery Specialists has been deemed a Center f Excellence in Bariatric Surgery by the American Sciety f Bariatric Surgery and Blue Crss Blue Shield. Our bariatric surgery prgram takes a multidisciplinary apprach. In additin t my initial surgical evaluatin, a dietician will educate yu regarding all aspects f yur pstperative diet. A psychlgist will evaluate and educate yu prir t surgery. Exercise prgrams and supprt grups are als strngly encuraged and will play a vital rle in keeping yur weight ff lng-term. It will take several weeks t cmplete these evaluatins. The cst f these cnsultatins may nt be cmpletely cvered by insurance cmpanies. Mst insurance cmpanies will prvide cverage fr the surgery and several pstperative visits. Please check with yur insurance cmpany t see what yur individual plan will cver. Laparscpic techniques, using several small incisins rather than ne large incisin, have made bariatric surgery safer. We perfrm the Laparscpic Rux-en-Y gastric bypass, The Laparscpic Sleeve Gastrectmy, Laparscpic Adjustable Gastric Banding (Lap-Band ). These prcedures will be explained further during yur initial visit. The chance f a successful utcme after weight lss surgery is greatly affected by yur knwledge and preparatin fr the surgery. Surgery is nly ne part f the ttal treatment f besity and its assciated medical diseases. Yu must educate yurself abut the weight lss surgeries ffered, hw they cause weight lss, pssible cmplicatins, and the necessary dietary and behaviral changes that yu will need t make after the surgery. Please read the enclsed infrmatinal bklet prir t yur first visit. Belw is a list f internet sites that are very infrmative. I strngly urge yu t spend a great deal f time investigating this subject prir t yur appintment. Realize Website Lap-Band Website Weight Lss Surgery Inf American Sciety f Bariatric Surgery Yu can als find my educatinal and training backgrund n ur website: I lk frward t wrking with yu. Sincerely, James A. Harris, M.D.

2 James A. Harris, MD, FACS Gastrintestinal and Laparscpic Surgery Castal Surgery Specialists 1411 Physicians Drive Wilmingtn, NC Phne: Weight Lss Questinnaire (page 1 f 3) **PLEASE COMPLETE ALL THREE PAGES OF THIS QUESTIONNAIRE AND RETURN TO IT TO THE OFFICE ASAP** Tday s Date Date f Birth Age Name Address Phne Numbers: hme: wrk: cell: Scial Security Number Race Occupatin Marital Status: Sing/ Mar/ Separ/ Div/ Wid Spuse Name Spuse Occupatin Insurance Cmpany Name Hw did yu find ut abut Dr. Harris and the Bariatric prgram? Did a physician refer yu here fr weight lss surgery? If yes, list name: What is the mst yu have ever weighed? Current Weight Height Lwest weight in past 5 years Highest weight in past 5 years Desired weight after surgery Number f years yu been verweight? Number f years > 100 punds verweight? List physicians yu have seen in the past 5 years: Name f yur current Primary Care Prvider: Name/Specialty/City Name/Specialty/City Name/Specialty/City Name/Specialty/City What is the average # f visits t yur medical physicians? Mnthly Yearly Obesity Related Illnesses (Please circle ALL that apply) High Bld Pressure Hw lng? Diabetes Hw lng? Are yu n Insulin? Yes/N Pulmnary Emblism (bld clt in lungs) Arthritis Where? Sleep Apnea (If yes, are yu n CPAP? (Yes/N) Crnary Artery Disease (heart disease) Pulmnary Hypertensin Mycardial Infarctin (heart attack) Asthma r COPD/emphysema Strke Gastresphageal Reflux Disease (GERD/heartburn) Cardiac Arrhythmias Urinary Stress Incntinence Cngestive Heart Failure Fungal Skin Infectins Hyperchlesterlemia (high chlesterl) Pseudtumr Cerebri Hyperlipidemia (increased lipids/triglycerides) Venus stasis dermatitis r ulcers Deep Venus Thrmbsis (bld clts in legs) Depressin/Anxiety r Mental illness Other Medical Prblems and Hspitalizatins:

3 Weight Lss Questinnaire (page 2 f 3) Past Surgeries/Operatins: Any type f weight lss surgery Date Gallbladder - Open r Laparscpic Date Hysterectmy Date Appendectmy Date Reflux/Hiatal Hernia Repair Type Date Surgery n Stmach: Type Date Other Abdminal Surgeries Date Other surgeries: Current Medicatins/dses/schedule Allergies t Medicatins: Scial Histry With whm d yu live? Alchl Intake (amunt per day) Beer Wine Liqur Have yu ever been addicted t alchl? Have yu ever been addicted t drugs? Have yu ever smked cigarettes n a regular basis? D yu currently smke cigarettes? Cigarettes (packs per day) Hw many years? Quit date What d yu d fr fun r leisure? Number f Pregnancies Number f Children Delivered Sleep Histry (Yu may skip the next five questins if yu have been diagnsed with sleep apnea.) 1. Have yu been tld yu stp breathing during sleep? Yes / N 2. D yu snre? Yes / N 3. Are yu excessively tired during the day? Yes / N 4. D yu have high bld pressure? Yes / N 5. Is yur neck size >17 inches (males) r >16 inches (females) Yes / N Family Histry Please list any diseases, syndrmes, r cancers that run in yur family. Hw des yur weight influence yur life style?

4 Diet Prgram Length f Prgram Amunt f Weight Lst Date/Year Weight Watchers TOPS Overeaters Annymus Diet Center Behavir mdificatin NutriSystem LA Weigh Lss Physician Directed Weight Lss Prgram Dietician Cunseling Physician s Weight Lss Center Atkins Diet Lw Calrie Diets Liquid Diets Optifast Jenny Craig Others (Please specify) Weight Lss Questinnaire (page 3 f 3) Diet Pills Didrex (benzphetamine) Inamin, Adipex-P, Fastin, Obytrim (phentermine) Tennuate Dspan (diethylprpin) Meridia (sibutramine) Xenical, Alli (rlistat) Fen-Phen Redux Over-the-Cunter Pills (specify) Over-the-Cunter Pills (specify) Exercise Plans: Walking/Running/Aerbics (circle all that apply) Physician directed exercise prgram Weight training/gym member Others:

5 Are yu a Candidate fr Weight Lss Surgery? James A. Harris, MD, FACS Gastrintestinal and Laparscpic Surgery 1411 Physicians Drive Wilmingtn, NC Phne: (910) Fax: (910) STEPS TO WEIGHT LOSS SURGERY AT COASTAL SURGERY SPECIALISTS STEP 1: CALL THE OFFICE AND SPEAK WITH THE BARIATRIC COORDINATOR All prspective candidates must speak with the Bariatric Clinic Crdinatr (at x132) befre we can schedule yur first ffice cnsultatin with Dr. Harris. Yu will be asked several questins ver the phne t determine if yu meet the minimum requirements fr weight lss surgery. STEP 2: DETERMINE IF YOUR INSURANCE PLAN WILL HELP PAY FOR WEIGHT LOSS SURGERY If yu are planning t have yur surgery cvered by insurance, yu need t determine if cverage is included within yur insurance plicy. We als recmmend checking yur surgical benefits s yu may plan financially fr surgery. Yur insurance carrier may exclude cverage fr weight lss surgery, s it is imprtant fr yu t d the fllwing prir t setting up yur first visit. Call yur insurance carrier and make sure yur plan prvides cverage fr weight lss surgery. Yur insurance carrier may request the name f the surgery and the CPT/ICD-9 cdes. Insurance cmpanies use the fllwing cdes t identify the type f prcedure: Laprscpic Adjustable Gastric Banding (Lap-Band ): Laprscpic Gastric Bypass: Laprscpic Sleeve Gastrectmy: Diagnsis Cde (ICD-9) fr Mrbid Obesity: STEP 3: FILL OUT THE WEIGHT LOSS SURGERY QUESTIONNAIRE AND RETURN IT TO THE OFFICE. Once yu have cmpleted the phne cnsultatin, yu will then be mailed a Weight Lss Surgery Questinnaire and a Weight Lss Surgery Packet. The Weight Lss Surgery Questinnaire must be filled ut cmpletely and legibly. The questinnaire shuld be drpped ff at the ffice r mailed back prmptly t Castal Surgery Specialists, Attn: Bariatric Crdinatr. Since having prper scial supprt is crucial t the lng-term success f yur weight lss surgery, we recmmend that yu plan t bring yur spuse, family member, r a clse friend with yu t the first cnsultatin. STEP 4: BEGIN ORGANIZING YOUR MEDICAL RECORDS PRIOR TO YOUR FIRST OFFICE VISIT. Begin t request yur medical recrds frm the past five years which include peridic weight and bld pressure measurements as well as any dcumented cnditins r illnesses assciated with being verweight. Please try t have these recrds faxed t the Bariatric Crdinatr r bring them with yu n the day f yur first ffice visit. Request a referral frm yur Primary Care Physician (if required by yur insurance cmpany). STEP 5: FIRST OFFICE CONSULTATION At yur first visit yu will have an initial cnsultatin with Dr. Harris. If yu are felt t be an apprpriate candidate, yu will be invited t attend a grup meeting t be held later that afternn. In this grup meeting, all types f weight lss surgeries ffered at Castal Surgery Specialists will be described in detail by Dr. Harris. Indicatins, risks, benefits, and pssible cmplicatins f weight lss surgeries will als be discussed. There will be ample time fr any questins yu

6 and yur family members may have at the end f the meeting. Please plan t stay until 5:30pm the day f yur first appintment. STEP 6: MEET WITH A PSYCHOLOGIST (STEPS 6-8 MAY BE DONE IN ANY ORDER UNLESS OTHERWISE SPECIFIED) Once evaluated and deemed a ptential candidate by Dr. Harris, yu will be asked t call the Chrysalis Center and schedule an appintment with a psychlgist. Chsing surgical weight lss is a serius decisin and requires that yu are in the best mental health. It is imprtant t make sure that yu are ready fr the significant lifestyle changes that surgery will bring. Yu must btain clearance frm the psychlgist at the Chrysalis Center befre scheduling the secnd surgical cnsultatin and btaining clearance fr surgery. Insurance may cver yur cnsultatin with the psychlgist, but this is NOT guaranteed. STEP 7: ATTEND NUTRITIONAL CLASSES WITH OUR REGISTERED DIETICIAN Yu are required t attend 2 pre-p nutritin classes instructed by Chaundra Evans RD, LDN. These classes are typically held the 1 st and 3 rd Wednesday f each mnth frm 4:00-5:30pm. Yu must participate during the class and cmplete the required hmewrk prir t scheduling yur 2 nd ffice visit. The nutritin classes cst $200 which cvers tw pre-p nutritin classes and yu will have access t ur RD at any time pst p with questins r cncerns at chaundra@chyrsaliscenter-nc.cm. Chaundra will als be present at the supprt grup ccasinally thrughut the year. This class is nt cvered r reimbursed by insurance. Yu will be prvided with a nutritin packet cntaining all the essential infrmatin fr pre and pst-p nutritin guidelines. STEP 8: ATTEND A BARIATRIC SUPPORT GROUP MEETING We require that yu attend a Bariatric Supprt Grup Meeting Prir t the SECOND visit at the ffice. These meetings are held at NHRMC AHEC Classrm C every secnd Mnday f the Mnth at 6:00pm. A flyer with a map and directins is included in the weight lss surgery packet. STEP 9: CALL TO SCHEDULE A SECOND OFFICE VISIT (SEE ATTACHED WEIGHT LOSS SURGERY CHECKLIST) Once yu have cmpleted all f the items n the WEIGHT LOSS SURGERY CHECKLIST, as well as any ther preperative recmmendatins, yu may call the Bariatric Clinic Crdinatr t schedule a secnd ffice visit. At this visit yu will meet with Dr. Harris (r his Physician Assistant) and yur health recrds and evaluatins will be reviewed. If yu are deemed an apprpriate candidate fr weight lss surgery, then we will submit the apprpriate paperwrk t yur insurance cmpany fr pre-apprval. STEP 10: INSURANCE PRE-APPROVAL FOR SURGERY Our Bariatric Clinic Crdinatr will wrk with yu and yur insurance carrier t btain pre-apprval fr yur surgery. Yu will nt be scheduled fr surgery until all required dcumentatin has been received and we have received insurance pre-apprval fr yur surgery in writing. This prcess can be very labr intensive and may take frm 2-8 weeks. If yu are nt apprved fr surgery by yur insurance cmpany, then smene frm ur ffice will cntact yu and discuss what actins need t be taken t appeal yur claim. STEP 11: SCHEDULE A SURGERY DATE When we receive insurance pre-apprval frm yur insurance cmpany, yu will be cntacted by ur surgery scheduler t schedule a surgery date. At that time yu will be given any additinal preperative infrmatin. STEP 12: START YOUR PREOPERATIVE DIET TWO WEEKS PRIOR TO SURGERY Studies have shwn that reducing the size f the liver preperatively decreases surgery time and surgical cmplicatins. Fr this reasn, we require that yu fllw a pre-p lw carbhydrate diet which is limited n mre than 60g f carbhydrates per day fr tw weeks prir t yur surgery. Please nte that it is very imprtant that yu fllw this diet prir t yur surgery. This will help reduce yur surgical risks which can be life-threatening.

7 James A. Harris, MD, FACS Gastrintestinal and Laparscpic Surgery 1411 Physicians Drive Wilmingtn, NC Phne: (910) Fax: (910) WEIGHT LOSS SURGERY CHECK LIST In rder t expedite yur evaluatin fr weight lss surgery, yu will need t prvide the fllwing medical dcumentatin prir t yur SECOND appintment with Dr. Harris r his Physician Assistant. This infrmatin is usually available frm yur medical physician(s). Please have the fllwing dcumentatin mailed r faxed t Bariatric Crdinatr at Castal Surgery Specialists prir t yur secnd visit. Fax number: (910) Five years f medical recrds dcumenting yur weights and bld pressures. (These weights and bld pressures must be supplied frm within an ffice nte, r if dcumented n a flw sheet, a crrelating ffice nte must be supplied.) Current Thyrid stimulating hrmne (TSH) lab test. This test shuld be n mre than 1 year ld. Current Hgb A1C lab test (nly if yu have Diabetes Type I r Type II). This test shuld be n mre than 6 mnths ld. Current H.pylri bld test. ( Gastric Bypass nly & Tricare nly) This test shuld be n mre than 6 mnths ld. A letter frm yur primary care physician, t include: 1. Prir attempts t lse weight (i.e. diets, diet pills, exercise plans, etc.) 2. Obesity related medical prblems. 3. Medical clearance fr Gastric Bypass Surgery. (Please see attached sample letter) OTHER REQUIREMENTS: Tricare participants will need a Chest X-ray and an EKG. Any ther requirements specified by yur insurance carrier and/r Dr. Harris r ther Healthcare prfessinal. Attend a Psychlgical Cnsult at the Chrysalis Center Attend tw Nutritin Classes with ur Registered Dietician Attend at least ne Bariatric Supprt Grup Meeting Nte: We must have the written evaluatins frm yur psychlgical and nutritin assessments prir t scheduling yur secnd visit.

8 EXAMPLE REFERRAL LETTER Dear Dr. James Harris, Mr. /Ms. De is a very cmpliant, mrbidly bese 40 year ld patient wh has been under my care fr the past five years. During this time he /she has attempted numerus cnservative weight lss treatments including diet mdificatins, weight lss medicatins, and exercise prgrams. Only shrt term results have ccurred. He/she has many related c-mrbidities including hypertensin, diabetes mellitus, sleep apnea and chrnic back pain. All these cnditins wuld greatly benefit frm weight lss. There are n cntraindicatins frm a medical standpint t cntinue with the gastric bypass surgery. The patient s thyrid functin tests, recent Hgb A1C, and medical recrds, including weights and bld pressures, are included with this letter. I d feel that verall this patient wuld greatly benefit frm weight lss surgery. Thank yu fr yur participatin in Mr. /Ms. De s care. If yu have any questin r cncerns, please feel free t cntact my ffice at Thank yu. Sincerely, Jhn Smith, M.D.

9 COASTAL SURGERY SPECIALISTS James A. Harris, MD, FACS Bariatric Supprt Grup Bariatric Supprt Grup Meetings When: Where: Secnd Mnday f every mnth, 6-7:00 p.m. NHRMC Auditrium New Hanver Reginal Medical Center (see belw) Wh: Preperative and Pstperative patients and family Pull int the main driveway and turn left int the Betty Camern Wmen's and Children's Hspital. Park in the lt and enter via the main entrance. Take the elevatrs (they are at the left) t the first flr. Exit, walk thrugh the waiting area and take the hallway until yu reach the Auditrium, lcated n the left. If yu g t the SEAHEC library yu have gne t far.

10 James A. Harris, MD, FACS Gastrintestinal and Laparscpic Surgery Castal Surgery Specialists 1411 Physicians Drive Wilmingtn, NC Phne: (910) Fax: (910) T: REQUEST FOR MEDICAL RECORDS RELEASE Patient Name: Date f Birth: Sc. Sec. # Date(s) f recrds t be requested: Type f recrds t be requested: Initial Cnsult Office Visits CT/MRI Labs/Meds Pathlgy Radigraphs --Office visits (including Weights and Bld Pressures) Other: PATIENT AUTHORIZATION I, the patient r legal guardian, authrize the abve requested medical recrds t be released by yur facility t Castal Surgery Specialists, PA at the fllwing: Castal Carlina Surgical Assciates, PA 1411 Physicians Drive Wilmingtn, NC Attentin: Bariatric Crdinatr Fax: (910) Patient/Guardian Signature Witness Please Fax Medical Recrds t Attentin: Bariatric Crdinatr / / Date / / Date 1411 Physicians Drive Wilmingtn, Nrth Carlina Telephne: (910) Fax: (910)