Womack Army Medical Center Department of the Army WAMC Stop a 2817 Reilly Road MXCX-DOS-GS - Bariatrics Fort Bragg, NC PHONE: (910)
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1 Womack Army Medical Center Department of the Army WAMC Stop a 2817 Reilly Road MXCX-DOS-GS - Bariatrics Fort Bragg, NC PHONE: (910) Surgical Weight Loss Program DATE: / / Name Address Street City State Zip Code address TELEPHONE: Home Work Cell SPONSOR S SS# PATIENT S SS#: Gender: male female Date of Birth / / Race: Caucasian Hispanic African American Asian Native American Other Who Referred You? Reason for Referral Occupation: Place of Employment: Employment Status: Full time Part time Self-Employed Homemaker Student Retired Disabled 1
2 PEOPLE LIVING IN YOUR HOUSEHOLD NAME AGE RELATIONSHIP HEALTH CARE PROVIDERS/MEDICAL Primary Care Physician: Phone: Address (if off-post): Fax: HEALTH CARE PROVIDERS MENTAL HEALTH Therapist or Mental health Counselor Address: Phone: Fax: Please list all other medical health providers and specialist. If you need more space, list additional providers names, specialties, addresses, telephone and fax numbers on the back of this page. Provider name: Specialty: Address: Phone: Fax: Provider name: Specialty: Address: Phone: Fax: Provider name: Specialty: Address: Phone: Fax: 2
3 Alcohol, Tobacco, and Non-prescription Drug History Current use: List all alcohol, tobacco, and non-prescription drugs and the amounts that you currently use. List any additional products on the back of this page. Type of Product Amount per day Per Week Alcohol: Tobacco: Drugs: When did you stop or plan to stop using? Alcohol: Tobacco: Drugs: Family History Please list any relatives that have a history of any the following conditions your parents, grandparents (maternal/paternal), siblings, or your children have ever experienced. Obesity Diabetes Heart Disease Stroke High Cholesterol/Triglycerides Cancer Prescription Medications, Supplements and Remedies Please list all your current medications, supplements and remedies. If you need additional space, please continue on the back of this page. Prescription drugs, dosages and purpose (including psychiatric medication and birth control. Please use back of form for additional space. ) Medication Dosage/How Often Purpose 3
4 Over the counter drugs: Vitamins/supplements/herbal remedies: Allergies to prescription medications: Allergy Reaction HOSPITALIZATIONS Please list all inpatient hospitalizations, including psychiatric and substance abuse treatment. If you need additional room, please continue on the back of this page. Approximate Date Problem Hospital/Treatment Facility 4
5 PREVIOUS NON-BARIATRIC SURGERIES Procedure: Anti-reflux procedure Bowel resection Breast cancer, mastectomy Breast Cancer, biopsy Breast cancer, radiation CABG Removal of gallbladder Hip replacement Hysterectomy Knee replacement Laminectomy Nissen Fundoplication Peripheral vascular Tubal ligation Vasectomy Procedure C-section Other PREVIOUS BARIATRIC SURGERIES Bilopancreatic diversion (BPD) Gastric banding, adjustable Gastric band, non-adjustable Gastric bypass, (Roux-en-Y) open Gastric bypass(roux-en-y) laparoscopic Sleeve gastrectomy Gastric bypass, mini loop Intestinal Bypass Gastric bypass, banded Vertical banded Gastroplasty BPD with duodenal switch Other (Please list) Year: Original weight: lbs Estimated? Actual? Lowest weight achieved lbs estimated actual Surgeon: Have you ever had an adverse reaction to anesthesia/sedation? Y N (If you answered yes, please comment) Has any of your relative had an adverse reaction to anesthesia/sedation? Y N (If you answered yes, please comment) 5
6 Current Medical Conditions Please check box and add information. Heart and Circulation: Chest pain/coronary artery disease/angina Congestive Heart Failure Irregular or rapid heart beat (arrhythmias) Peripheral vascular disease Leg swelling (edema) Hypertension/high blood pressure Stroke Blood Clots/Deep Vein Thrombosis (DVT) Other: Comments Lungs: Shortness of breath at rest walking on flat ground on stairs/hills Asthma COPD (emphysema, chronic bronchitis) Pulmonary Embolism (Blood clot in the lungs) Sleep Apnea CPAP settings Pulmonary Hypertension Other: Gastrointestinal/GI: Gastro Esophageal Reflux (GERD) Heartburn Ulcers Crohn s Disease/Ulcerative Colitis Frequent Diarrhea Frequent constipation Gallbladder stones removed Fatty liver Colon hemorrhoids polyps Liver hepatitis Cirrhosis Other: Endocrine: Diabetes High cholesterol, high triglycerides Infertility Menstrual irregularities Polycystic Ovarian Syndrome Thyroid Hypothyroidism (Underactive) Hyperthyroidism (Overactive) Excessive hot or cold feeling 6
7 Visual Changes Changes in your voice Recent increase in thirst or urination Abnormal hair growth Numbness or tingling in your hands or feet Other: MEDICAL HISTORY Blood: Anemia Iron Deficiency Other: Musculoskeletal: Back pain Gout Arthritis type: Fibromyalgia Other: _ Psychiatric: Depression Bi-polar Disorder Eating Disorder Anorexia Bulimia Anxiety Other: Other: Urinary Stress Incontinence Pseudotumor Cerebi Abdominal Skin/Pannus irritation/infection Abdominal Wall Hernia Kidney Disease Kidney Stones Other: Comments 7
8 WEIGHT AND WEIGHT LOSS HISTORY Current weight or best estimate Current Height Weight 1 year ago Are you at your highest weight ever? Yes No If your answered no, what was your highest weight and when? Please check all previous weight loss methods that you have tried. List any additional Commercial diet programs Weight Watchers Diet Workshop Jenny Craig OA TOPS Nutrisystem Other: Other: Liquid Diets Optifast HMR Slimfast Other: Prescription diet medications Redu (dexfenfluraramine) Pondimin (fenfluramine) Phen-Fen Phentermine (Fastin,Adipex) Amphetamines Meridia (sibutramine) Other: Other Herbal and non-prescription remedies Epedra, ma huang Other herbals: Over the counter diet aids Other: WEIGHT AND WEIGHT LOSS HISTORY Therapy and Other Programs Behavior therapy Psychotherapy Exercise programs Feeding Ourselves Self initiated or fad diets. Please list: Medical and health Care Treatments Previous gastric surgery/stapling Jaw wiring Other surgery: Acupuncture Hypnosis Other: 8
9 Cardiac Questionnaire Gastric bypass is an intermediate risk surgery according to the American Heart Association. In order to best prepare you for surgery please fill out the following questions appropriately. 1. Have you had heart surgery with in the last 3 years? 2. Have you been seen recently by your heart doctor? 3. Do you have a heart condition? If yes, please describe. 4. Do you get chest pain with exercise? 5. Have you ever had a heart attack? 6. Have you been treated for heart failure? 7. Do you have diabetes mellitus? 8. Can you carry groceries in from the car? 9. Can you vacuum the house? 10. Can you mow the lawn using a push mower? 11. Have you ever had a stroke? 12. Do you have high blood pressure? Is it treated? Where is it normally at when you get it checked? 13. How fast can you walk a mile? 14. What is your age? 9
10 OBSTRUCTIVE SLEEP APNEA SCREENING QUESTIONAIRE 1. Do you snore loud enough to be heard through closed doors? Yes No 2. Do you often feel tired, fatigued, or sleepy upon waking? Yes No 3. Has anyone observed you stop breathing during your sleep? Yes No 4. Do you have high blood pressure? Yes (if yes) Are you being treated for it? Yes No No 5. Is your Body Mass Index more than 35? Yes No (BMI= Your weight in pounds X 703/your height in inches X your height in inches) 6. Are you over 50 years old? Yes No 7. Is your neck circumference greater than 40 cm? Yes No 8. Are you a male? Yes No 10
Womack Army Medical Center Department of the Army WAMC Stop a 2817 Reilly Road MXCX-DOS-GS - Bariatrics Fort Bragg, NC PHONE: (910)
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PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
Name: DOB: Age: Weight Loss Surgery Follow-Up Data. Height Weight LB WL BMI EBW %EWL
Weight Loss Surgery Follow-Up Data Height Weight LB WL BMI EBW %EWL How many meals per day do you eat? On average, how long does it take you to eat a meal? How many times a day do you snack? How many 8oz.
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
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG
ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG DATE SOC. SEC. NUMBER FULL NAME DATE OF BIRTH ADDRESS: STREET TOWN STATE ZIP PHONE: HOME WORK CELL EMPLOYER OCCUPATION ADDRESS
PATIENT INFORMATION. Are we currently seeing one of your family members at our practice, or have we previously? YES patient s name:
PATIENT INFORMATION Date Name Address First Middle Last City State Zip Home # Cell # Check this box to authorize text messaging for confirming and reminders Email Check this box to authorize our office
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
PATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Address: City: State: Zip code: Mobile Phone: ( ) - Alternate Phone: ( ) - Employer: ID#: Group#: Policyholder (Subscriber Name): Relationship:
Please complete and mail, fax, or e-mail to: Meg El Haoud, RN Bariatric Program Coordinator 788 8th Ave. SE Level 3, Suite 300 Cedar Rapids, IA. 52401 Fax: (319) 398-6748 Phone: (319) 398-6747 melhaoud@mercycare.org
New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):