Consent to Contact Patient

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Sydney Patterson
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1 Consent to Contact Patient Name: Date of Birth: Nickname: MaidenName: Mailing Address: City: State: Zip: By providing my landline, cell number, and/or address, I expressly consent to receiving communications from Mercy Medical Center, your staff, or your contractors including collection agents to any landline, cell number, , or other electronic communication I provide or that you later acquire for me. You may use this information to contact me live or leave voic , text, , or pre-recorded messages regarding my account(s) and/or health care service(s) provided to me. You may use an auto dialer to contact me or to deliver messages to me. Providing you with my contact information is not a condition of receiving health care services. I consent to being contacted by (check all that apply): Yes No Home phone: Cell phone: Work/other phone: Yes No You may discuss my health information (test results, my health status, and any other information related to my health) with the following people: Name(s): By signing this Consent to Contact Patient form, I acknowledge that I have read (or have had read to me) and understand the contents and the consent I am providing, and I agree that this information may be used to contact me live or by voic , text, , or pre-recorded message. I permit a copy of this consent to be used in place of the original. Patient Signature: Witness Signature: Date and Time: Date and Time: Reviewed: Initials Date/ Time Initials Date/ Time Initials Date/ Time Initials Date/ Time Initials Date/ Time Initials Date/ Time 1

2 Dr. Mark Smolik Phone: Fax: Last, name, first name, middle initial Date of Birth Sex Age Marital Status Street Address Home Phone Cell Phone M S D W City State Zip Code Work Phone Alternate Phone # Employer s Name Occupation Employer s Street Address (include City, State, Zip Code) Religious Preference (statistical purpose only) Race (statistical purpose only) EMERGENCY CONTACT INFORMATION Emergency Contact Home Phone Work Phone Relationship Street Address (include City, State, Zip Code) Please check your policy for surgery benefits. You must attach a copy of the front and back of your Insurance card Primary Insurance Secondary Insurance Address Address Customer Service Phone Number Customer Service Phone Number Policy or ID Number Policy or ID Number Subscribers Name Subscribers Name Subscriber Date of Birth Subscriber Date of Birth Relationship to Patient Relationship to Patient Subscriber s Employer, Address, Telephone Number Subscriber s Employer, Address, Telephone Number Date Attended Community Lecture: Primary Care Physician: I am interested in: (Circle one) Gastric Bypass /RNY Gastric Sleeve I authorize release of medical information necessary to process claims for health insurance and disability benefits, and request that payment be made directly to my surgeon for services rendered. A copy of this authorization will be accepted as valid as the original. Signature: Date: 2

3 The information requested in this questionnaire is very important. To give you the best care, and to obtain your insurance approval, we must have complete answers. Please be thorough. Blue or black ink only please. How much do you weigh? How tall are you? Current BMI Ideal Body Weight Excess Body Weight Office Use Only WEIGHT HISTORY LIFE EVENT Age Weight Start of High School High School Graduation Marriage Lowest Weight in Past 5 Years Highest Weight in Past 5 Years In your own words, please describe what you hope to accomplish and how you believe your life will change by losing weight: Who will be your support person through this process? (Support person must be at least 18 years old) EXERCISE and ACTIVITY Do you currently exercise? If yes, please specify amount/frequency: What kind of exercise do you like to do? DIETARY HISTORY Approximate age when you first seriously dieted: How many years have you been morbidly obese (100 lbs. or more over weight)? How much water do you consume per day? 3

4 To assist in the prior authorization process we request you provide details on your previous diet attempts. This is a major area of concern in meeting the requirements of your insurance company. Most insurance carriers insist you try formal weight loss programs before they will agree to pay for bariatric surgery. Please include: 1. The name of the program, for example: Weight Watchers, Nutri-System, etc./ Personal diets (informal) 2. The approximate date and length of time you were on the program. 3. What the program included, for example: low carb, calorie counting, prepared meals etc. 4. What exercise you did while on the program. 5. How much weight you lost and subsequently regained when you stopped following the program. 6. Finally, what meetings did you attend and what diet counseling was done. Please take your time in filling out this form and providing as many details as you can. This will be submitted to the insurance company along with the psychiatric evaluation, education documents, and letters from the primary care doctor and dictation from the surgeon visit. DIET HISTORY Dates Program Weight Loss/Regain EXAMPLE to Weight Watchers Went to the meetings and weighed two times a week for 9 months. Lost 50 lbs but gained back 25 after stopping 4

5 DIET HISTORY CONTINUED Dates Program Weight Loss/Regain 5

6 Medical History Have you had, or do you have, any of the following illnesses or symptoms? 1. Heart Disease If yes, year diagnosed Diagnosis: Do you have, or have you had: Chest Pain Heart Attack /M.I. (myocardial infarction) CABG (coronary artery bypass graft) Palpitations Pacemaker Defibrillator/ AICD Cardiac Rehabilitation (with diet counseling documentation) 2. High Cholesterol Medications 3. High Triglycerides Medications 4. High Blood Pressure Medications 5. Diabetes 6. Asthma Have you had these tests/procedures: Echocardiogram Angiogram Abnormal EKG Stress test to rule out cardiac problems Controlled with: Diet Medication: Insulin Non-Insulin Last Hemoglobin A1C: Gestational: ER visits/last 2 years Steroids last 2 years 7. Shortness of Breath If yes, Can walk blocks Stairs flights 8. Chronic Obstructive Pulmonary Disease (COPD) or Emphysema Past Hospitalization for treatment of COPD Oxygen Dependent 6

7 9. Sleep History Total Sleep Time: Snoring: Daytime Sleepiness: Use Oxygen at Night: Difficulty Staying Asleep? Stop breathing at night? Morning Headaches: Insomnia: Difficulty tolerating anesthesia? Epworth Sleepiness Scale: Please answer each question by using the following numbers. 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Sitting and Reading: Watching television: Sitting inactive in a public place, like a theater or a meeting: As a passenger in a car for an hour without a break: Lying down to rest in the afternoon: Sitting and talking to someone: Sitting quietly after lunch when you ve had no alcohol: In a car while stopped in traffic: Total score: 10. Sleep Apnea Syndrome Last sleep study month/year CPAP/BIPAP/AutoPAP used 11. Heartburn? 12. Esophagitis/reflux (GERD)? Medications 13. Hiatal hernia? 14. Stomach ulcers? 15. Coughing or choking at night? 16. Gallbladder disease? Removed 17. Leakage of urine with laughing/coughing/sneezing? 18. Renal Disease/Insufficiency If yes, on Dialysis? 7

8 19. Low back pain? If yes Seen by Chiropractor? Orthopedic Surgeon? Seen by Family Doctor? Medications 20. Joint pain? multiple joints/hips/knees/ankles/feet Describe From arthritis? From injury? Yes No Describe If yes Seen by Chiropractor? Orthopedic Surgeon? Seen by Family Doctor? Medications? 21, Functional Status (Select the one that best describes you) Independent Partially dependent- requires some assistance from another person for activities of daily living (bathing, dressing, etc.) Totally dependent- requires total assistance for all activities of daily living (bathing, dressing, etc.) 22. Ambulation (Select the one that best describes you) Independent Cane or walker Use assistive device most of the time (wheelchair or scooter) 23. Connective tissue disorder? Describe 24. Lupus or Multiple Sclerosis? Describe 25. Autoimmune Disorder? Describe If yes, taking Corticosteroids or Immunosuppressant Medication? 26. Venous Stasis Disease? If yes Do you have edema or swelling in your legs? Scaly or thick skin on your legs? Leg ulcers or open sores on your legs? Wear compressive stocking on your legs? 27. Have you ever had a deep venous thrombosis (DVT), a blood clot or a pulmonary embolism? If yes, explain. On a therapeutic dosage of anticoagulation medication? Do you have vena cava filter inserted? 8

9 28. Gout? 29. Have you ever had Psychiatric treatment? Have you ever had a Psychiatric Hospitalization? When was your treatment: Where: Current psychiatric treatment by: Psychiatrist Therapist Psychologist Primary Care Physician If presently in treatment/therapy, name of provider. 30. Have you ever been diagnosed with an eating disorder? If yes, please specify: 31. Female Patients: Last PAP/Pelvic exam: Last Mammogram: History of infertility: History of Polycystic Ovarian Disease Do you presently use: Birth control pills List type: Estrogens List type: Other Contraceptive method: Pregnancy #1 Year Weight at Start at delivery Pregnancy #2 Year Weight at Start at delivery Pregnancy #3 Year Weight at Start at delivery Pregnancy #4 Year Weight at Start at delivery Bra size: Skin depressions from bra straps? Do you have shoulder pain? 32. Have you ever had (check all that applies): Hepatitis Blood Transfusion AIDS/HIV Exposure Thyroid Problems Colitis Kidney Disease Bleeding Abnormality Endoscopy Colonoscopy Sigmoidoscopy Eating Disorder If yes, please explain: 33. Please list all Major Surgeries Date 9

10 34. Please list all Major Illnesses Date Treatment 35. Allergies: Are you allergic to any medications? If yes, please list medication and reaction: Allergic to: Surgical tape: Latex: Iodine: Other Allergies: Please list all prescription and over the counter medications you are currently taking Medication Dose and Frequency Why do you take this medication? Do you currently use tobacco? If yes, Type: Amount and Frequency: Are you willing to quit? Are you a former smoker: Quit Date: Use E-cigarettes: Do you use alcohol? Amount and Frequency: History of alcohol or drug abuse? 10

11 FAMILY HISTORY Family Member Living? Age If Deceased, age History of obesity Mother Y N Father Y N Maternal Grandmother Y N Maternal Grandfather Y N Paternal Grandmother Y N Paternal Grandfather Y N Sibling Y N Sibling Y N Sibling Y N Sibling Y N Illness/Cause of Death Please indicate if there is a family history of: Diabetes Lung disease, Asthma or Emphysema Heart Disease Kidney Disease High Blood Pressure Bleeding tendency or Blood Disorder High Blood Cholesterol Breast Cancer Colon Cancer Current Personal Physicians: Name Address Location Telephone Fax Primary Care Internist Pulmonologist Endocrinologist Orthopedist Psychiatrist/Counselor/ Psychologist Cardiologist Sleep Apnea Doctor Other How long have you been seeing your Primary Care Physician? 11

12 SYSTEM REVIEW Please check yes or no to symptoms you currently experience, or have experienced in the past. Feel free to add any additional problems or information. HEAD, EYE, EAR, NOSE & THROAT YES NO CARDIOVASCULAR Cont d YES NO Stuffy nose Blue toes Runny nose Blue finger Hay fever Loss of pulses Sinus trouble GASTROINTESTINAL Earache Heartburn Headache Nausea Blurry vision Vomiting Double vision Belching fluid in throat Haloes around lights Burning in throat HEAD, EYE, EAR, NOSE & THROAT YES NO GASTROINTESTINAL YES NO Loss of night vision Food sticking in chest Buzzing in ears Pain in stomach Ringing in ears Burning in stomach Discharge from ear Acid stomach Loss of hearing Diarrhea Dizziness Constipation Vertigo Pain with bowel movement Loss of balance Blood in stools Sore throat Hemorrhoids Lump in throat Fissures Trouble swallowing Cramps Pain with swallowing Gassiness Hoarseness Irritable colon RESPIRATORY Colitis Cough Intolerance to fatty foods Wheezing Right upper abdomen pain Shortness of breath at night Bloating Use of two pillows GENITOURINARY Blood in sputum Pain with urination Out of breath with exertion Trouble starting urine Wake up at night short of breath Trouble stopping urine Wake up at night coughing or choking Small urine stream Asthma Blood in urine Emphysema Kidney stones Bronchitis Bladder stones CARDIOVASCULAR Kidney failure Palpitations Nephritis Pounding heart Urinary tract infections Skipping heartbeat Frequent urination Pain in chest Getting up at night to urinate Pain in neck Leakage of urine w/ cough or sneeze Pain in arm(s) MEN: Squeezing of chest Discharge from penis Heart attack Loss of erection Heart murmur Painful erection Abnormal electrocardiogram WOMEN: Irregular heartbeat Vaginal discharge High blood pressure Vaginal bleeding Pain in leg(s) Pain with intercourse Cold feet Irregular periods 12

13 ENDOCRINE (GLANDULAR) YES NO NEUROLOGICAL YES NO Low thyroid Dizziness Hyperthyroid Vertigo Goiter Falling to the side Grave s disease Falling at night Thyroid nodules Numbness X-ray to thyroid Tingling Diabetes Pins and needles feelings Adrenal gland tumor Weakness of any muscles Frequent flushing Twitching of muscles Frequent heavy sweating Weakness of grip MUSCULOSKELETAL Shakiness Pain in joints Tremors Swelling of joints Fainting MUSCULOSKELETAL YES NO NEUROLOGICAL YES NO Redness of skin over joints Convulsions Warm joints Fits Fluid in joints Loss of consciousness Arthritis PSYCHOLOGICAL Broken bones Nervousness Sprains Anxiety Low back pain Depression Hip pain Thoughts of suicide Knee pain Suicide attempts Ankle pain Hospitalization for emotional problems Foot pain Psychiatric treatment Flat feet Psychological counseling Slipped disk Herniated disk Sciatica 13

14 PLEASE CONTACT YOUR INSURANCE COMPANY TO RECEIVE A QUOTE OF BENEFITS FOR BARIATRIC SURGERY Please be sure to attach a copy of both sides of your insurance card. Questions for Your Insurance Company Today s Date Insurance Company Insurance Company Contact: Does my plan have benefits for Bariatric Surgery or Morbid Obesity (our surgeries are normally done as inpatient procedures)? What happens if your insurance carrier states you have no coverage? Insurances are constantly changing and we have other services that may be of interest to you. Please mail in your information and we will work to see if there is some way we can still be of help for you. In my plan is there a maximum benefit pertaining to bariatric surgery for: CPT (Gastric Bypass) or CPT (Gastric Sleeve) What is my Deductible? What is my Co- Insurance? What is my Copayment? Once we receive this and your health and history forms we will do further research into your insurance requirements. When you attend your Initial RN visit we will help explain what all this information you ve gathered will mean to you. 14

Patient Name: (Last), (First) (Middle) Street Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: SSN:

Patient Information Patient Name: (Last), (First) (Middle) Street Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Email: SSN: Date of Birth: Gender: M F Marital Status: M D S W Employer