Legacy Weight and Diabetes Institute

Transcription

1 General Information (Please Print Clearly) Address: Last Name Legal First Name M.I. Home Phone Address City State Zip Work Phone Social Security Number - - Sex Male Legacy Weight and Diabetes Institute Employer Date of Birth: Bariatric Patient Application 1040 NW 22 nd Ave. Suite 520, Portland, OR Phone: Fax: / / Month Day Year Employer Address Female Race White Asian American African American Alaska Native American Indian Pacific Islander Other Hispanic Non Hispanic (Check all that apply) Do you speak English? Yes No If No, do you need an interpreter? Highest level of Education 6 th grade or less Some high school GED/high school Some college 2 year degree 4 year college Advanced degree Can you read at a 6 th grade level? Yes No Referred to Legacy Weight Management by (if referred by a patient please include their name): Insurance Information PRIMARY Insurance Name Address Policy Holder Name SECONDARY Insurance Name Address Policy Holder Name Group Number I.D. Number Group Number I.D. Number Insurance Company Phone Employer Insurance Company Phone Employer

2 Family History: Are you adopted? Yes No Is your father alive? Yes No Age at time of death: Cause of death: Did he have/had: Diabetes Heart Disease High Cholesterol Is your mother alive? Yes No Age at time of death: Cause of death: Did she have/had: Diabetes Heart Disease High Cholesterol Social History: Occupation: Employer: Highest level of education: Marital Status: Single Married Divorced Widow Separated Living with significant other Work: Full Time Part Time Retired Self Employed Homemaker Student Disabled Date started: Unemployed Active combat experience Yes No Ages of Children:,,,, Number of Persons Living in Home: Surgeries: Please list all surgeries you have had. 1. Year: 2. Year: 3. Year: 4. Year: 5. Year: 6. Year: 7. Year: Have you ever had surgery for heartburn/hiatal hernia Yes No Have you ever had a surgical procedure for weight loss? Yes No If yes, which procedure(s)? Lapband Bypass Sleeve When (year)? Where? Was it later reversed? Yes No Date: / /

3 Medications: Please list all prescription, over the counter medications, vitamins and supplements you are taking. Name of drug Dosage/Mg Frequency List any previous psychiatric medications you have taken, and for what reason: Allergies: Please list any medication allergies you have Personal Physicians: (Please provide full name) Primary Care: City Office Phone Cardiology/Pulmonary: City Office Phone Referring Physician: City Office Phone

4 Check Yes to any of your following medical or psychological conditions. Skin rash or condition Bleeding problems Heart condition a. Heart attack or MI (myocardial infarction) b. Angina or chest pains c. Congestive Heart Failure d. Heart Rhythm Disturbance Blood clot in legs Blood clot in lungs High Blood Pressure Edema or water retention Leg ulcers Sleep Apnea Do you use CPAP/BiPAP Lung problems such as Asthma, recent Pneumonia, COPD or emphysema GERD (heartburn or acid reflux) Stomach ulcers Liver problems Gallbladder problems Colon or Intestinal problems Hernia, what type Arthritis Joint replacement Fibromyalgia Back pain Urinary problems such as kidney stones, infections, leakage of urine Irregular menstrual periods Polycystic ovarian syndrome Diabetes Thyroid condition High Cholesterol Headaches such as migraines Stroke or TIA (Transient Ischemic Attack) Epilepsy or seizure disorder Cancer If yes, what type? Depression Bipolar disorder (manic depression) Anxiety or panic disorder Personality disorder Psychosis Substance use disorder Other mental health conditions Other medical condition Comments

5 Have you ever seen a counselor? Yes No If yes, when and how many sessions did you attend? Dates # of sessions Provider/Location Reason Have you ever been psychiatrically hospitalized? Yes No If yes, when and for how long? Have you ever been in drug or alcohol treatment? Yes No If yes, when and for how long? History of abuse? Verbal/emotional Physical Sexual Legal History: No legal problems DUI/DWI Misdemeanor Felony Civil suit Bankruptcy Substance Use: History of smoking or tobacco use? Yes No If Yes, how many years total have you smoked or used tobacco? How many cigarettes would you average per day? When did you quit? still smoking/using tobacco Currently using e-cigarette Alcohol use: Current use: Yes No Quit date: If yes, how much do you drink? drinks per week/month/ year (circle one) Has your drinking ever been a problem or very heavy? Yes No Illicit drug use (marijuana, cocaine, amphetamines, etc.)? Current use: Yes No Never Quit date? Drugs used: Circle or fill in any that apply to you. Fatigue or feeling tired. Recent illness. Skin sores or hard to treat infections. Blood transfusions or blood products. Eyeglasses, eye disorder, hearing difficulty, hearing aids, snoring, C/PAP use, hoarseness, trouble swallowing, sores in mouth, dentures, partial plate or bite guard. Short of breath, cough, wheezing. Heart related chest pains, heart murmur or palpitations (rapid heart rate or skipping beats) Cardiac study:. Swelling or fluid retention in legs or varicose veins.

6 Frequent hunger, Heartburn, abdominal pain, nausea, vomiting, diarrhea, constipation, black tarry or bloody stools, hemorrhoids. Date of last Colonscopy or stomach study:. Bladder or kidney infection. Frequent Urination. Problems with sexual functioning. Female: Last menstrual cycle or date / age of menopause. Menstrual cycle is regular or skips months, with heavy, normal or light flow. Method of birth control. Date of last Pap smear:. Date of last Mammogram:. Pain or limitation in motion: Back, knees, feet, ankles, shoulders, joint pain or other Difficulty walking with use of: Cane, walker, wheelchair or scooter. Date of last Bone Density or Dexa Scan: Headaches, fainting, seizures, dizziness, weakness, unusual numbness or trouble with balance. How many hours of sleep do you get at night? Is your sleep interrupted? Do you feel rested in the morning? Do you take naps? Weight History: Current weight: lbs Height: ft in The most you ve ever weighed: lbs Date: Since age 18, the least you ve weighed: lbs Date: For how long: Please circle any of the weight loss programs or diets you have tried in the past: Atkins, South Beach. Grapefruit, Cabbage Soup, Slim Fast, Prism, Zone Diet, Blood Type Diet, Medifast/Optifast, Diet Pills (Metabolife, Dexatrim), Herbalife, Mayo Clinic, Calorie counting, Increased Exercise, TOPS, Overeaters Anonymous, American Heart Association Diet, Weight Watchers, Jenny Craig, LA Weight Loss, Qsymia, Belviq, Phentermine,other: Food Intake Do you eat breakfast every day? Yes No Number of meals eaten per day? Number of snacks eaten per day? Servings (based on 8 oz) of the following fluids you typically consume in a day Water Non-fat or 1% milk 2%milk Whole milk Fruit juice diet soda regular soda Coffee/tea Coffee drinks (latte, mocha etc) Fruit or sport drinks Beer hard liquor Wine Other Meals per week eaten in a fast food restaurant (include drive thru /convenience stores) Breakfast: Lunch: Dinner:

7 Meals per week eaten in a traditional restaurant, cafeteria, coffee shop: Breakfast: Lunch: Dinner: Please list any food intolerances or special diet needs that you follow now List any foods that you dislike and refuse to eat? How many hours do you watch tv each day? How many hours are you on the computer or playing video games? Snack while watching tv? Yes No While on the computer? Yes No Please recall all food and drink consumed yesterday including your best estimate of serving size: Breakfast Lunch Dinner Snacks Was this a typical day of eating? Yes No Physical Activity: Do you limit any activities because of your weight or pain? Yes No If yes, where do you have pain? When you walk outside your home, check any of the devices you use. Rate the effect on your ability to walk by the following areas: Ankle Pain Knee Pain Hip Pain Back Pain Shortness of Breath Numbness in Feet Balance Problems Cane Walker Wheel chair Electric cart Rate your pain in the following areas Ankle/Foot Knee Hip Back 1 Not Limited 1 No Pain Does pain interfere with sleep Yes No Extremely limited Extreme pain Are you able to exercise? Yes No If yes, how often? If yes, describe exercise you do and your tolerance to it. **Remember to attach a copy of your insurance card (front & back) to this application***