Health History Form: Bariatric Surgery
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- Bridget Wilkerson
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1 Health History Form: Bariatric Surgery It is important that ThedaCare and Midwest Bariatric Solutions have a complete understanding of your health while preparing you for weight loss surgery. The bariatric team will use the below information to determine your specific requirements for surgery coverage based on your insurance and health history. You will receive these requirements in your personal pathway letter the night of the informational session. The pathway letter and the informational session are intended to help you determine if weight loss surgery is the right option for you. There are no commitments! Submit this form within 7 days of your scheduled informational session to receive your pathway letter at the session. Form may be submitted one of the three ways: 1) bariatrics@thedacare.org 2) Fax Number: ) Mailing Address: Attn: Midwest Bariatric Solutions 100 Medical Plaza, Suite 400 Neenah, WI **Your pathway letter will be mailed if this form is submitted in less than 7 days of the scheduled informational session. Contact our program at with any questions while filling out the form. We will be happy to assist you! Date you attended Informational Session / / Name: Date of Birth: / / Age: Gender: Male/Female Occupation: Address: address: Phone Number: - - Cell Phone Number: - - Work Phone Number: - - May we leave a message on Home Phone? Yes No Cell Phone? Yes No Work Phone? Yes No Best way to reach you? Time? Which surgery do you wish to have? Roux-en-Y Gastric Bypass Revision of Prior Bariatric Surgery Sleeve Gastrectomy ORBERA Balloon Placement Health History Form: Bariatric Surgery 1
2 The below information is use to determine your insurance coverage and requirements for weight loss surgery. If at any time your insurances changes, notify us at Insurance Plan Name: Member ID Number: Group Number: Insurance Member/Subscriber Name: Relationship to Member/Subscriber: Customer Service Phone Number: Insurance Address: Weight Related Illnesses Have you had, or do you have any of the following illnesses of symptoms? Heart Disease: Angina If Yes, year diagnosed M.I. (myocardial infarct) If Yes, year diagnosed CABG (Coronary artery bypass graft) If Yes, year diagnosed Abnormal EKG If Yes, year diagnosed Stress Test If Yes, year diagnosed Palpitations If Yes, year diagnosed Other Heart Diagnosis: If Yes, year diagnosed High Cholesterol/Triglycerides:: If Yes, year diagnosed High Blood Pressure: If Yes, year diagnosed Diabetes: (Type: ) If Yes, year diagnosed As a result of your diabetes, do you have Nephropathy (kidney problems): Comments: Asthma: If Yes, year diagnosed As a result of your asthma, in the past 2 years, have you been prescribed steroids? Other lung/ breathing problems: Diagnosis: Year you were diagnosed Sleep Apnea: If Yes, year diagnosed CPAP/BI-PAP used regularly: Last sleep study: / (month/year) Treated by Dr. ***Note: We will need a copy of your last sleep study if you wish to pursue surgery. If you are in the ThedaCare system, we can retrieve these documents. Health History Form: Bariatric Surgery 2
3 Heartburn or Reflux: If Yes, year diagnosed Diagnosed with a Hernia: Type: Surgery to repair hernia? If Yes, year/surgeon Gallbladder Disease: Gall bladder removed? Laparoscopic or Open If Yes, year Leakage of Urine: Joint Pain: Hips Knees Ankles Feet Back Have you seen a specialty doctor for these problems? Dr. List any weight related injuries or trauma: Circulation problems: Comments: Edema (swelling) If Yes, location: Thick scaly skin Varicose Veins Leg ulcers Currently healed? If No, how are they being treated? Current Weight & Height: Weight pounds Height Feet Inches Social History (Habits) Tobacco Use (smoke/chew) If Yes, frequency: Are you willing to quit? Previous smoker? If Yes, quit date: Do you use alcohol? If Yes, how often? week/month/year) Number of drinks each time Street Drug Use? If Yes, type of drug used: Frequency: Past Medical History Identify which of the following serious illnesses you have been diagnosed with: Hepatitis AIDS/HIV Colitis Kidney Disease Bleeding disorder Thyroid disorder Irritable Bowel Rheumatoid Arthritis Multiple Sclerosis Blood Clot Sickle Cell Disease Fibromyalgia If Yes to blood clot: Where When Treatment Did your clot move to your lung? (Pulmonary Emboli) List below all serious illnesses and hospitalization you have experienced as an adult: Health History Form: Bariatric Surgery 3
4 Major illness Date Treatment Major Surgery Date Have you had a previous weight loss surgery? If Yes, type: Surgeon: Date: Physicians Please list any physicians that you are currently seeing: Primary Care Physician: Gastroenterologist: Cardiologist: Pulmonologist: Psychologist/ Psychiatrist/ Therapist Orthopedic: Allergies Allergic to any medications? If Yes, list each medication and your reaction: Allergic to: Surgical Tape Latex Iodine Other If Yes, list: Health History Form: Bariatric Surgery 4
5 Medications Please list ALL medications that you are currently taking including vitamins, herbal supplements, and over the counter medications. Medication Name Dosage Frequency *If more room is needed, please attach a separate sheet of paper with additional medications Do you take Medication for blood thinning (Coumadin/Warfarin/Plavix)? Medications with Aspirin in it? NSAIDS (Ibuprofen/Aleve/Advil/Celebrex/ Motrin/ Toradol)? Mother Father Maternal Grandmother Maternal Grandfather Fraternal Grandmother Fraternal Grandfather Sibling Sibling Sibling Family History Living Current Age Age at Death Cause of Death Please indicate if there is a family history of: Obesity Kidney Disease Lung Disease, asthma, emphysema Diabetes High Blood Pressure Bleeding tendency or Blood disorder Heart Disease Breast Cancer High Cholesterol Blood Clot Colon Cancer Pulmonary Emboli (blood clot to lung) Sickle Cell Disease Health History Form: Bariatric Surgery 5
6 Please completely fill out the following questionnaire. This will determine whether or not you may need to be tested for sleep apnea prior to surgery. Have you been diagnosed with Sleep Apnea by a physician? Yes No If Yes, are you being treated for your sleep apnea with C-PAP/BiPAP? Yes No If you have not been diagnosed with Sleep Apnea, please complete the following: 1. Do you snore? 6. How often do you feel tired or fatigued after your sleep? No nearly every day Do not know 3-4 times a week If you snore: 2. Is your snoring? 7. During your wake time, do you Slightly louder than breathing feel tired, fatigued or not up As loud as talking to par? Louder than talking Nearly every day Very loud. Can be heard in adjacent rooms 3-4 times a week 3. How often do you snore? Nearly every day 8. Have you ever nodded off 3-4 times a week or fallen asleep while driving No 4. Has your snoring ever bothered 9. Do you have high blood other people? pressure? No No Do not know 5. Has anyone noticed that you quit breathing during your sleep? Nearly every day 3-4 times a week Health History Form: Bariatric Surgery 6
7 Please sign to verify that all the information you have provided is accurate and to the best of your knowledge. Signature: Date / / Please read and sign the following authorization: By my signature below I am authorizing Midwest Bariatric Solutions, Theda Clark Medical Center s Bariatric Coordinator, and/or their designees to request medical information from the physicians I listed as part of this health history questionnaire on page 6. The purpose for their request of this information is so that they may coordinate my care as I pursue and investigate bariatric surgery and/or care alternatives. The types of information that they may request includes, but is not limited to: history and physical exams, discharge summaries, consultation reports, laboratory and imaging studies, clinic visits, and nutrition records. Signature: Date / / Please print your name: Updated 11/15 Health History Form: Bariatric Surgery 7
Patient History Form: Bariatric Surgery Page 1 of 9
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TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female
Place Patient Sticker Here Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female Social Security # Marital Status: Single Married Divorced Widowed Ethnicity: Non Hispanic
History & Review of Systems Screening. Medical History
History & Review of Systems Screening Patient name: Date: / / Pharmacy name:_ Primary Care Physician: Referring Physician: Height: Weight: R or L handed Medical History Please tell the doctor if you have
PATIENT HEALTH INFORMATION SHEET
. Norman J. Brodsky, M.D. Board Certified Michael D. Gauwitz, M.D. Diplomate, ABR Taghrid A. Altoos, M.D. Radiation Oncology Hiral K. Shah, M.D. PATIENT HEALTH INFORMATION SHEET NAME: DATE OF BIRTH: AGE:
Patient Information. Legal Name: First Middle Last. Street City State Zip
Patient Information Legal Name: Home Address: First Middle Last Street City State Zip Gender: (circle one) Male Female Date of Birth: Social Security #: - - mm / dd / yyyy Email: Marital Status: Primary
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
Questionnaire. General Questions: DOB: Current address: Daytime phone #: Evening phone #: Current occupation:
Submit your completed questionnaire to the Women s Center Coordinator Fax: 713.798.2689 or Mail: Women s Center for Comprehensive Care Baylor Clinic 6620 Main Street, Ste. 1225 Houston, TX 77030 Questions?
Spouse Information Spouse Name: Work Phone: ( ) - Emergency contact (Not living in same household) Name: Relationship: Contact Phone: ( ) -
BayChoice Surgeons Bariatric & Laparoscopic Surgery Kenneth Hollis, M.D., FACS 11914 Astoria Boulevard Ste. 125 Houston, TX 77089 Ph. 281-482-5300 Patient Information Legal Name Last: First: M.I. Birth
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
NEUROSURGERY PATIENT INTAKE FORM
NEUROSURGERY PATIENT INTAKE FORM Surgical Movement Disorders Center Name: DOB: / / Age: Gender: Male Female (circle one) Height: feet inches Weight: lbs What is the main reason for your visit? Are there
MCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM
Patient name: MRN #: Current Medications (prescription and over the counter medications including vitamins, herbs, aspirin, antacids, injectables, hormones and birth control medication) If you brought
Adult Health History for New Patient
Adult Health History for New Patient Name: Birth Date: Today s Date: Preferred Pharmacy (name and location): Your answers on this form will help your health care provider get an accurate history of your
Patient Registration Form
Patient Registration Form Name: Today s Date: FIRST MIDDLE LAST Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip: