Patient Questionnaire

Transcription

1 Patient Questionnaire Dr. Peter Kwon Dr. Ramon Rivera Dr. Wayne Weiss Dr. Jaime Cepeda Middletown, NY Phone: (845) Fishkill, NY / Cornwall, NY Phone: (845) Suffern, NY Phone: (845) Page 1 of 8

2 Dear Prospective Patient: Thank you for your interest in our Bariatric Surgery Program. We offer comprehensive Preand Post-operative care, provided by a multidisciplinary team of excellent compassionate professionals. We strive to maximize your success with weight loss and improvement of associated medical conditions. We offer the Lap-Band, the laparoscopic Roux-en-Y Gastric Bypass, and the Sleeve Gastrectomy procedures. As of January 2017 Tri-State Bariatrics has performed over 8000 bariatric surgeries. Dr. Peter Kwon attended Columbia University College of Physicians and Surgeons. He received his general surgery residency training at the Cedars-Sinai Medical Center in Los Angeles. Dr. Kwon has more than 28 years of practice experience and is certified by the American Board of Surgery and is a Fellow of the American College of Surgeons (FACS). He is also a Fellow of the American Society for Metabolic and Bariatric Surgeons. Dr. Kwon is the founder and director of Tri- State Bariatrics. He is also the Medical Director of Bariatric Surgery of the Surgical Weight Loss Institute at Catskill Regional Medical Center. Dr. Kwon strives to provide high quality surgical care that is current and proven in a compassionate, courteous, and professional manner. Dr. Ramon Rivera is a board certified surgeon specializing in Minimally Invasive Surgery, Bariatric Surgery and Advanced Gastrointestinal surgery procedures. Dr. Rivera is the Medical Director of Bariatric Surgery at Good Samaritan Hospital in Suffern, NY. He completed medical school at Upstate Medical University at Syracuse, his residency at Drexel University College of Medicine; and his laparoscopic fellowship at Washington University School of Medicine. He is a fellow of the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (FACS). He has over 15 years of laparoscopic surgery experience. His primary interest lies in the study of long-term weight loss success and minimally invasive surgery. Dr. Wayne Weiss was educated at New York University Medical Center and has over twenty years of surgical experience. He is the Bariatric Medical Director at St. Luke s Cornwall Hospital. Dr Weiss is a board certified surgeon specializing in General Surgery, Surgical Critical Care, and Bariatric Surgery procedures. He is a trauma surgeon for over 25 years with an established record of excellence. He is a fellow of the American Society for Metabolic and Bariatric Surgery and the American College of Surgeons (FACS). Dr Weiss has over 20 years of laparoscopic surgery experience. He is the Bariatric Medical Director for St Luke s Cornwall Hospital, NY. Dr. Jaime Cepeda Jr. is a board certified surgeon specializing in General, Bariatric and Vascular surgery procedures. Dr Cepeda is certified by the American Board of Surgery and is a Fellow of the American College of Surgeons (FACS). He is the Bariatric Medical Director for Bon Secours Community Hospital in Port Jervis, NY. Dr Cepeda obtained his Bachelor of Science from North Carolina State University, his Doctorate of Medicine from the University of North Carolina at Chapel Hill, NC and his Masters in Business Administration from East Carolina University. He completed his residency at Saint Vincent s Hospital in New York City. Thank You Tri-State Bariatrics Team Page 2 of 8

3 Tri-State Bariatrics Office Locations and Contact Information: Suffern, NY 156 Route 59, Suite A2 Suffern, NY Phone: Toll Free: (877)-OPT HEALTHY Fax: 845: Middletown, NY 384 Crystal Run Road, Suite 201 Middletown, NY Phone: Toll Free: (855)-Eat-Rite Fax: 845: Fishkill, NY 200 Westage Business Center, Suite 119 Fishkill, NY Phone: Toll Free: (855)-Eat-Rite Fax: Cornwall, NY 21 Laurel Ave Cornwall, NY Phone: Toll Free: (855)-Eat-Rite Fax: Page 3 of 8

4 Patient Registration Patient Information Person Responsible for Bill (Guarantor) Last Name: Name: First Name: Address: Middle Name: Address: Relationship to patient: City: State: Date of Birth: Zip: Social Security No.: Home Phone: Phone: Mobile Phone: Sex: Emergency Contact Information Date of Birth: Name: Social Security No: Relationship: Ethnicity: Phone: Mobile Phone: Pharmacy: Location: Lab: Location: Name of Insurance Plan: Policy Holder (If other than patient) Last Name: First Name: Middle Name: Address: City: State: Zip: Date of Birth: Sex: M F Employer Name: Name of Insurance Plan: Policy Holder (If other than patient) Last Name: First Name: Middle Name: Address: City: State: Zip: Date of Birth: Sex: M F Employer Name: Primary Insurance Secondary Insurance Patient s relationship to policy holder: ID/Certification No.: Policy / Group No.: Patient s relationship to policy holder: ID/Certification No.: Policy / Group No.: The above information is true to the best of my knowledge: Patient / Guardian Signature: Date: Page 4 of 8

5 Allergies (drugs & food) Drug / food Name: Date of Birth: Type of Reaction Medications Pharmacy Name: Phone: Name of Medication Strength (dose) How often Purpose Vaccine Pneumococcal Vaccine Yes No (If Yes Date: Provided by: ) Flu Vaccine Yes No (If Yes Date: Provided by: ) Family History Family member Grandmother Grandfather Grandmother Grandfather Mother Father Brother Sister Son Daughter Grandson Granddaughter Obesity Diabetes High Blood Pressure Sleep Apnea High Cholesterol Any Addictions Cancer Other Page 5 of 8

6 Name: Date of Birth: General Information Primary Care Provider: Phone# How long has he/she been your doctor: How long at current weight: How Long have you been overweight: (years) At what age did you first start dieting: (age) What was your greatest single weight loss: (pounds) How did you loss this weight (be specific): How long did you sustain that weight loss: Education 8 th Grade 11 th Grade 2yr College 4yr Post Grad Occupation: Employer: Marital Status: single married separated divorced widowed? Live alone or with others: Able to care for self: Yes, No How many children do you have? daughter(s) son(s) How many siblings do you have? brother(s) sister(s) Smoking History never smoked former smoker occasional smoker every day smoker how many packs/day since what age chewing tobacco None 1/day 2-4/day 5+/day yrs of use Illicit drug use yes no yrs of use Alcohol use none occasional moderate heavy yrs of use Parents marital status: Married, Separated, Divorced, Widowed Did you have any history of childhood abuse? yes no General stress level Low, Medium, High Have you had any legal issues (ie. arrests, bankruptsy, lawsuits)? yes no Previous Surgeries Surgery Date Reason Previous weight loss surgery Last colonoscopy (male/female) Last prostate (male) GYN: Last menstrual cycle: Last PAP: Last Mamo: Page 6 of 8

7 Past Medical History Name: Date of Birth: Do you now have or have you had in the past? Please circle answer: Do you have any beliefs that prohibit the use of blood or blood products? Yes No Anxiety Disorder Yes No Bi-Polar Disease Yes No Depression Yes No Self-harm/Self cutting Yes No Asthma Yes No Suicide attempts Yes No Sleep Apnea Yes No Schizophrenia Yes No Use of C-Pap/Bi-Pap Yes No Alcohol use disorder Yes No COPD / Emphysema Yes No Substance use disorder Yes No Blood clots Yes No Eating disorder Yes No Arrhythmia / A-Fib Yes No Learning disorder Yes No Coronary artery disease Yes No Kidney Disease Yes No Hypertension (High Blood Pressure) Yes No Gout Yes No Myocardial Infarction (Heart Attack) Yes No Liver Disease Yes No Stroke Yes No Bleeding Abnormality Yes No High Cholesterol Yes No Cancer Type Yes No Hypothyroid Yes No Connective tissue disease: Yes No Sarcoid/Lupus Diabetes Mellitus Yes No HIV Yes No Insulin non-insulin Gallstones Yes No Hepatitis A, B or C Yes No GERD (Gastric Reflux /Heartburn) Other: Arthritis Yes No Other: Mobility Assessment Instructions: please circle the level of difficulty you have for each activity today. Able to do without any difficulty Able to do with little difficulty Able to do with moderate difficulty Able to do with much difficulty Unable to do Laying flat Rolling over Moving-lying to sitting Sitting Squatting Bending / stooping Balancing Kneeling Standing Walking short distance Walking long distance Walking outdoors Climbing stairs Hopping Jumping Running Pushing Pulling Reaching Grasping Lifting Carrying Total Page 7 of 8

8 Nutrition History Goal Weight: lbs Name: Date of Birth: Highest Weight/age at that weight: lbs / age Lowest Weight/ age at that weight: lbs / age Vitamins: Herbals: Food Allergies: Food Intolerances: Do you eat 3 meals a day? Breakfast types of foods: Lunch types of foods: Dinner types of foods: Snacks types of foods: Time of day snacking occurs: Food preferences: Caffeine intake: None, Occasional, Moderate, Heavy Beverage (s) of choice for the day: Amount consumed: ounces Do you have beverages with your meals? Yes No Eating pace: Slow, Medium, Fast Portion Size: Small, Medium, Large Who does the food shopping / preparation? How often do you eat out? Are finances a concern when purchasing food? Motivation for eating (examples: stress boredom, depression etc.) Type of physical activity currently: Frequency /duration of activity: Please list weight loss attempts (diets, exercise, supplements, etc.) Page 8 of 8