INITIAL EVALUATION FORM
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- Erica Bradford
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1 INITIAL EVALUATION FORM The following information is very important to your health. It will help us to give you the best possible medical/surgical care. Please take the time to complete this questionnaire. PLEASE PRINT AND USE BLACK INK. Name: (First) (Middle) (Last) Age: Date of Birth: / / Occupation: Primary Care Physician: Phone: ( ) Fax( ) Other Physician(s): Phone: ( ) Fax( ) Other Physician(s): Phone: ( ) Fax( ) Have you been referred to us? m Yes m No If yes, by whom? How did you hear about us? m Primary Care Physician m Friends/Family m Internet: Specify Website m Other: What is your primary reason for making an appointment? Are you seeking evaluation for weight loss surgery? m Yes m No At what age did you develop a significant weight problem? m Child m Teen m Adult Your highest weight? At age Are you on a restricted or special diet for any medical reasons? m No m Yes If Yes, Explain: In your opinion, what contributes to your excess weight? m Compulsive Eating m Eating too much fat/sugar m Nervous Eating m Stress m Lack of Exercise m Lack of Knowledge m Emotional Eating m Portion Size m Sweet Cravings m High Calorie Drinks INITIAL EVALUATION FORM 1/9
2 WEIGHT LOSS METHODS YOU HAVE TRIED: DIET LENGTH OF TIME YEAR WEIGHT LOSS m Appetite Suppressant Gum m Atkins Diet m Beverly Hills Diet m BioSlim m Dexatrim m Diabetic Diet m Diuretics m Herbal Remedies m Jenny Craig m Laxatives m Low Carbohydrate Diet m Low Fat Diet m Medifast m Meridia m MetaboLife m Metabolite m NutriSystem m Optifast m Overeaters Anonymous m Phen-Fen m Phentermine m Physician Supervised Diet m Redux m Richard Simmons Deal-A-Meal m Slim-Fast m South Beach Diet m Starvation Diet m The Grapefruit Diet m The Zone m TOPS m TrimSpa m Weight Watchers m Weight Loss Camp m Xenical m Other m Other INITIAL EVALUATION FORM 2/9
3 Have you or any of your family members ever had bariatric surgery? m Yes m No If yes, m Self m Mother m Father m Spouse m Brother m Sister If yes, what type of surgery was performed? m Gastric Banding m Gastric Bypass m Sleeve Gastrectomy m Don t know Other: Name of surgeon? Do you exercise regularly? m Yes m No If so, what type of exercise do you perform? How many times per week? How long do you exercise each time? Do you snore? m Yes m No Do you ever wake at night gasping for air? m Yes m No Has anyone ever told you that you stop breathing while asleep? m Yes m No Is it hard for you to fall asleep? m Yes m No Do you have or have been treated for an eating disorder? m Yes m No Has your appetite changed over the last six months? m Yes m No MEDICAL HEATLH HISTORY INFORMATION: Please indicate if you have ever suffered from any of the following conditions. Please include the name of the physician who is currently managing the condition. MEDICAL HISTORY CARDIAC m Coronary Artery Disease m MI ( Heart Attack) m Elevated Cholesterol/Triglycerides m Chest Pain m Congestive Heart Failure m Valvular Disease m Rheumatic Fever m Heart Murmur m Heart Arrhythmia (Irregular Heart Beat) m High Blood Pressure PULMONARY m Asthma m Pneumonia m Bronchitis m COPD (Emphysema) m Tuberculosis m Obesity Hypoventilation Syndrome m Pulmonary Hypertension PHYSICIAN INITIAL EVALUATION FORM 3/9
4 MEDICAL HISTORY PULMONARY (continued) m Sleep Apnea m Using CPAP/BiPAP Machine ENDOCRINE m Diabetes m Hyperthyroid m Hypothyroid m Adrenal (Cushing s) GASTROINTESTINAL m Reflux Disease (Heartburn) m Peptic Ulcer Disease m Gallbladder Disease m Liver Disease m Inflammatory Bowel Disease m Hiatal Hernia m Abdominal Hernia RENAL m Kidney Disease m Urinary Stress Incontinence m Kidney Stones PERIPHERAL VASCULAR DISEASE m Arterial Vascular Disease m Pulmonary Embolism m DVT (Phlebitis) m Superficial Phlebitis m Leg Ulcers m Varicose Veins CENTRAL NERVOUS SYSTEM m Stroke m Seizure m Cerebral Aneurysm m Arteriovenous Malformation m Pseudotumor Cerebri m Arterial Vascular Disease MUSCULOSKELETAL m Low back pain m Diagnosed Osteoarthritis/ DJD m Painful Joints PHYSICIAN INITIAL EVALUATION FORM 4/9
5 MEDICAL HISTORY MUSCULOSKELETAL (continued) m Autoimmune Disease m Gout m Gout m Fibromyalgia m Abdominal Skin/Pannus BLOOD DISORDERS m Anemia m Abnormalities with bleeding or clotting PSYCHIATRIC DISORDERS m Depression m Bipolar Depression m Anxiety m Schizophrenia m Anorexia m Bulimia CANCER Type: Treatment: Type: Treatment: PHYSICIAN OBSTETRICAL/GYNECOLOGICAL HISTORY m History of breast cancer m Pre-menopausal m Post-menopausal m Menstrual Irregularities m Polycystic Ovarian Syndrome m Number of Pregnancies: m Births: Term: Premature: Abortions: Living Children: m Have you ever had a hysterectomy? m Yes m No m If yes, indicate procedure m Vaginal m Abdominal m Have you ever had a C-Section? m Yes m No If yes, how many? m Have you ever had a Tubal Ligation? If yes, indicate procedure m Open m Laparoscopic INITIAL EVALUATION FORM 5/9
6 SURGICAL HISTORY: Please list all surgical procedures and year performed. If relevant specify if the surgery was done laparoscopic or open. SURGERY YEAR ALLERGY INFORMATION: Please list any known allergies and reactions ALLERGY REACTION INITIAL EVALUATION FORM 6/9
7 PHARMACY CONTACT INFO Name of Pharmacy: Phone: ( ) Address: MEDICATIONS Please list all prescribed and over the counter medications, vitamins and minerals you are currently using. MEDICATION DOSE TIMES PER DAY YEAR STARTED PURPOSE SMOKING/DRUG/ALCOHOL HISTORY Do you smoke cigarettes? m No m Yes, packs per day How many years? If you have smoked in the past, quit date: / / Do you drink alcohol? m No m Yes, drinks per week If yes, what type of alcohol? m Wine m Beer m Liquor m Mixed Drinks Have you ever had a problem with alcohol in the past? m No m Yes, when and for how long? Have you ever used any illicit drugs? m No m Yes, indicate drug used and how long ago? INITIAL EVALUATION FORM 7/9
8 PREVIOUS DIAGNOSTIC PROCEDURES Please indicate which of the following procedures you have had in the last year. Specify month in which they were performed. m EKG m Chest XRay m Lower GI m Sleep Study m Echocardiogram m Abdominal Ultrasound m Upper GI m Other m Stess Test m Colonoscopy m Pulmonary Function Test m Heart Catheterization m Upper Endoscopy m CT Scan (Body Area) FAMILY MEMBER ALIVE DECEASED DISEASE MOTHER FATHER BROTHER SISTER GRANDPARENTS CHILDREN m ADOPTED NO HISTORY OF BIOLOGICAL PARENTS Please list any specific questions or concerns that you may have so that your physician can address them at the time of your consultation: 1) 2) 3) 4) 5) 6) INITIAL EVALUATION FORM 8/9
9 Please describe in your own words why you are seeking surgical weight loss. (This will be part of your medical record) INITIAL EVALUATION FORM 9/9
Gender: M F Race: Caucasian African American Hispanic Other
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36320 Inland Valley Drive Suite 201 Wildomar, CA 92595 Name(last, first): Home Phone: Cell Phone: Emergency contact/ Phone: Relationship to Emergency Contact: E-mail address: Date of birth: SSN: Would
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Nutrition History and Questionnaire
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Welcome to Deaconess Weight Loss Solutions.
deaconess.com/weightloss Name Date of Birth CSN (office use only) MRN (office use only) NUTRITION ASSESSMENT QUESTIONNAIRE Welcome to Deaconess Weight Loss Solutions. We look forward to supporting you
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
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Emergency Contact Name Relationship Phone Primary Care Physician Phone Did a Physician Refer you to us? YES NO Physician Name
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Salt Lake Orthopaedic Clinic Initial Visit Form
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