Patient Medical History

Transcription

1 Date: The PMA Metabolic and Bariatric Weight Management Center 410 West Linfield-Trappe Road, Suite 100 Limerick, PA (610) Patient Medical History Name: Date of Birth: Age: Female Male ALLERGIES: Are you allergic to any medications? If yes, list what medications and describe the reaction below: Medication Reaction Are you allergic to any foods? Yes No If yes, list what foods and describe the reaction below: Food Reaction Do you have any other allergies? (dust, mold, weeds, etc.) Yes No If yes, please list the substances and describe the reaction below: Substance Reaction Are you allergic to latex products? (Example: foam rubber, tennis shoes, balloons) Yes No

2 Page 2 Patient Name: MEDICATIONS: Please list any medications you are currently taking (prescribed or over the counter): Drug Dose How Often Why SURGERY HISTORY: Have you had Stomach and/or Abdominal Surgery? Yes No If yes, please describe below: Surgery Year Problems or Complications Have you had any other surgeries? Yes No If yes, please describe below: Surgery Year Problems or Complications ANESTHESIA HISTORY: Have you or a family member ever had complications with anesthesia? Yes No If yes, please describe:

3 Page 3 Patient Name: SUBSTANCE USE: Do you Smoke? Do you drink alcohol? Do you use marijuana? Do you use other drugs? Yes No How much Number of Years Quit BREATHING AND LUNG HISTORY: Do you have any of the following breathing and/or lung problems? Asthma? Emphysema? Cough? Snoring? Sleep Apnea? Yes No Do you need extra pillows to help you breathe during sleep? Yes No If yes, how many pillows? Do you ever wake up at night short of breath? Yes No Do you experience shortness of breath: Yes No At rest? After any exertion? Climbing stairs? Do you have any breathing problems that interfere with everyday activity? Yes No If yes, please describe:

4 Page 4 Patient Name: HEART AND CIRCULATORY SYSTEM: Do you have or have you had any of the following heart and/or circulation problems: Congestive heart disease? Heart attack (MI)? High blood pressure? Low blood pressure? Irregular heart beat? Heart murmur? Chest pain? Swelling of hands and feet? Blood clots in legs or lungs? Varicose veins? Yes No Do any of these problems affect your everyday activity? Yes No If yes, how? Do you see a cardiologist? Yes No If yes, physician s name and phone number MUSCULOSKELETAL SYSTEM Do you have the following joint problems? Back Knees Hips Other Yes No Severity Details Do you have fibromyalgia? Yes No If yes, please describe:

5 Page 5 Patient Name: STOMACH AND DIGESTION HISTORY: Do you have any of the following stomach, digestion, intestinal, colon or related problems: Heartburn? Trouble swallowing? Ulcers? Gallstones High Cholesterol? Colitis? Diverticulitis? Crohn s Disease History of nausea/vomiting? History of diarrhea? Hemorrhoids? Yes No Are you diabetic? Yes No If yes, treated with Diet: Medication (pills) Insulin injections Do you check your blood sugar at home? Yes No If yes, how often? Last reading: OTHER MEDICAL HISTORY: Do you have or have you had any of the following general problems: Open or draining sores? Vision problems? Liver problems/hepatitis? Kidney problems? History of cancer? High or low thyroid? Yes No

6 Patient Name: FAMILY MEDICAL HISTORY: Patient Medical History Page 6 Do any family members have a history of medical problems (cancer, high blood pressure, diabetes)? Yes No If yes, please describe: Do any family members have a history of obesity? Yes No If yes, please describe: RECENT MEDICAL STUDIES DONE: Have you had any of the following medical tests done within the past year: Upper Endoscopy? Colonoscopy? Pulmonary Function Tests? EKG? Chest X-ray? Yes No Don t Know PSYCHOLOGICAL AND SOCIAL HISTORY: Do you have a problem with any of the following: Depression? Psychiatric Hospitalization? Hospitalized for suicidal attempt? Anorexia? Bulimia? Are you currently being seen by a psychiatrist/psychologist? Yes No If Yes, Year(s): How long have you been overweight? Do you have a supportive person(s) in your life?

7 Page 7 Patient Name: DIET HISTORY: Which of these SUPERVISED PROGRAMS have you tried? Personal Physician Optifast Physicians Weight Loss Weight Watchers Jenny Craig Nutri-System Weight Loss Clinic Other Years Attempted Weight (Lbs.) Loss Weight (Lbs.) Regained Which of these PERSONAL PROGRAMS have you tried? Fasting Slim Fast Deal-a-Meal Lo-cal/Lo-fat diets Other Years Attempted Weight (Lbs.) Loss Weight (Lbs.) Regained Notes: Patient Signature: RN/LPN/MA: Physician: Christopher J. Kaczmarski, M.D. Date: Date: Date:

8 Name: Date: Age (in years): Sex: Male or Female (circle one) How likely are you to doze off or fall asleep in the following situations, in contract to just feeling tired? 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. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3= high chance of dozing Situation Sitting and Reading Watching TV Sitting inactive in a public place (e.g. a theater or 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 Chance of Dozing