Mercy Metabolic and Bariatric Surgery Program Questionnaire

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Melvyn Garrett
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1 Mercy Metabolic and Bariatric Surgery Program Questionnaire Interested in bariatric surgery? Complete this form and return to us to be considered for evaluation: Sara Maduka, Mercy Metabolic and Bariatric Surgery Program Director Office: Cell: Fax: East Jefferson Street Suite 205 Iowa City, IA Name: Date: Age: Date of Birth: Sex: Address: State: Zip: Phone: Home: ( ) - Work: ( ) - Cell: Race/Ethnicity: African American Caucasian Hispanic Native American Asian Other What procedure are you interested in: Laparoscopic adjustable gastric band Laparoscopic Roux-en-Y gastric bypass Laparoscopic sleeve gastrectomy Insurance: Insurance #1: ID #: Group #: Policy Holder: Relationship: Customer Service Phone #: Insurance #2: ID #: Group #: Policy Holder: Relationship: Customer Service Phone #: How did you hear about our program? Web TV Radio Newspaper Seminar Mercy Employee Family/Friend Mercy Patient Insurance Company My Physician: Name: Phone #: ( ) - ) Do you currently smoke? Yes No Current Height: feet inches Current Weight: Highest weight since age 18: Lowest weight since age 18: Age when obesity began: 1

2 Currently or in the past six months, have you experienced any of the following: Yes/No Condition Yes/No Condition Yes/No Condition Abnormal belly pain Headache Rectal bleeding/pain Blood in stools Hearing loss/ear pain Shortness of breath Bowel habit changes Indigestion Sore throat/cough Chest pain Itching/rash Sweats Depression/anxiety Loss of sleep Unexplained weight loss Dizziness/fainting Nausea Vision changes/eye pain Excessive thirst Numbness Vomiting Excessive bleeding Pain/problems urinating Fever Poor appetite Other Health issues, past and present (please mark all that apply): Past/Present Condition Medication/Treatment (name, dose) High Blood Pressure Diabetes Sleep Apnea Daytime Sleepiness Snoring Reflux/Heartburn Heart Disease High Cholesterol High Triglycerides Joint Pain Back Pain Hip Pain Knee Pain Ankle and Foot Pain Foot Swelling Urinary stress/incontinence Blood Clots Stroke Shortness of breath Asthma Emphysema Headaches Migraines Kidney Disease Seizures Rashes Arthritis Cancer Irregular Periods Eating disorder Other (please explain) Notes (Office use) 2

3 Past/Present Psychiatric History Medicat ion Hospitalized* Dates Explain (next pg.) Depression No Yes Severe depression No Yes Schizophrenia/ No Yes Bipolar Anorexia/ Bulimia No Yes Do you see a psychologist, psychiatrist, or counselor for mental health issues? Yes* No (If so, please include a recent psychiatric evaluation including history, diagnosis, and treatment.) Continued Psychiatric History Explanations*: Medical History: (list any other conditions not addressed on previous page): Condition: Medication: Dosage: Condition: Medication: Dosage: Condition: Medication: Dosage: Current Mediations: Include prescription and over the counter: Medication: Dosage: How often: Medication: Dosage: How often: Medication: Dosage: How often: Pharmacy: Primary Care Provider: Surgical History (ALL surgeries and procedures, including those that are bariatric/for weight loss): Drug Allergies: Drug: Drug: Reaction: Reaction: 3

4 Family History: (Please mark all that apply) Father Paternal Grandfather Paternal Grandmother Father s Brothers Father s Sisters Mother Maternal Grandfather Maternal Grandmother Mother s brothers Mother s sisters Sisters Brothers Sons Daughters Severe Obesity Heavy Normal Weight Bariatric Surgery Diabetes Heart Disease Cancer Hypertension Blood Disease Personal History of Weight Gains and Losses (since age 18): No pattern Steady, gradual increase of weight Sudden increases of weight with pregnancies Variable weight gains and losses due to diet and exercise fluctuations Exercise History: I am unable to exercise due to: severe joint pain shortness of breath wheelchair/bedridden I am able to exercise but I do not have a regular routine I walk/run times per week for minutes I swim times per week for minutes I lift weights times per week for minutes Other (please describe): 4

5 Dietary History: Please check all that describe your daily eating pattern Less than normal Normal Overeat Binge Serious eating disorder Excessive snacking Do you eat/snack just before bed? Yes No Which meals do you regularly eat? Breakfast Lunch Supper Snacks What do you eat for breakfast, and how much? What do you eat for lunch, and how much? What do you eat for supper, and how much? What do you eat for snacks, and how much? Do you drink soda? No Yes: How many 12 ounce servings each day? Diet: Regular: Do you drink juice? No Yes: What kind? How many 12 ounce servings each day? Social and Personal History: Highest level of education: Occupation: Part-time Full-time Employer name: Do you have children? No Yes: how many? Marital Status: Single Married Separated Divorced Have you ever smoked tobacco? No Yes If yes, do you currently smoke? No: when did you quit? How many packs per day? Yes: year you started? How many packs per day? Have you ever used chewing tobacco: No Yes If yes, do you currently chew? No: when did you quit? How many cans per day? Yes: year you started? How many cans per day? Do you have a history of alcohol abuse? No Yes: when was your last drink? Do you consume alcoholic beverages? No Yes: how many drinks per week? 5

6 Do you have a history of drug/substance abuse? No Yes Do you currently use drugs? No: What drugs have you used? When did you quit? Yes: What drugs are you using? Female Reproductive History: Current method of birth control: Number of: Pregnancies: Vaginal deliveries: C-Sections: 1 st Pregnancy: (year) (age) pounds gained 2 nd Pregnancy: (year) (age) pounds gained 3 rd Pregnancy: (year) (age) pounds gained Age at first period: Did you breastfeed your babies? Yes/No How long? Have you ever taken birth control pills? Yes/No Date of last menstrual period? How long? Date of last PAP? Date and location of last mammogram? Family history of breast cancer? Yes/No Who? Summary of Weight Loss Attempts: Provide a list of supervised diet attempts over the past five years (start with most recent). Most insurers require monthly documentation for at least three to six months. 1. Medically Supervised: Monitored monthly by a licensed clinical professional (physician, physician assistant, nurse practitioner, licensed/registered dietitian) 2. Supervised by commercial program staff (Weight Watchers, Jenny Craig, etc.) 3. Self-Monitored 1) Name/type of diet: 2) Name/type of diet: 6

7 3) Name/type of diet: 4) Name/type of diet: I certify that the information I have provided is correct and complete to the best of my knowledge. Signature: Date: I have reviewed the preceding health history. Physician s Initials: Date: 7

Please complete and return this form to be considered for evaluation

Office use only: MRN BMI Please complete and return this form to be considered for evaluation Name Date Age Date of Birth / / Sex M F Address City State Zip code Preferred Daytime Phone: ( ) - Do you have