Name: DOB: Age: Weight Loss Surgery Follow-Up Data. Height Weight LB WL BMI EBW %EWL
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- Anastasia Green
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1 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. glasses of water do you drink per day? What is your usual portion size? ½ cup ¼ cup 1 cup More than one cup Which beverages do you drink daily? Coffee Tea 1 Soda Diet Soda Water Do you take any of the following supplements on a regular basis? Iron Calcium B12 Multivitamin Other What type of exercise do you perform on a regular basis? How often do you exercise? Have your comorbidities changes? Please use the following key: R=Resolved I= Improved U= Unchanged Diabetes High Blood Pressure Sleep Apnea GERD Arthritis Other How often do you experience the following symptoms? nausea Night Cough Reflux or heartburn Pain when eating Vomiting or regurgitation Have any of your medications changes? Y / N If yes, please list changes:
2 Please place a check in the column below that best describes how often you eat the following foods: Food Daily 2-3/wk 1/wk 1-2/mo 1-2/yr Never Meat (beef or pork) Poultry (chicken or Turkey Solid fruit (apple) Raw or lightly steamed vegtables Bread Rice Cooked Vegtables Casseroles Pasta Eggs Yogurt, dairy or cheese Fish Fried Foods Crackers or Chips Soups Ice Cream Alcohol Initial Evaluation for Weight Loss surgery Employed: F/T-P/T-Self-Retired- t Employed Height Present Weight Referring Physician: Primary Care Physician: Medical History (Check all that apply) High Blood Pressure Acid Reflux/Stomach Disorders Urinary Incontinence Diabetes Arthritis Asthma Heart disease High Triglycerides High Cholesterol Ankle/leg swelling Thyroid Problem Shortness of Breath Snoring Depression Hiatal Hernia
3 Record below major diets that resulted in a weight loss of 10 pounds or more (use additional pages as needed) Year Length of Diet Starting Weight # Of lbs. Lost Length of time weight stayed off Type of diet program At what age did you develop a significant weight problem? Are there events that are related to your weight gain? If so, what are they? Are you receiving any medical or psychological services at this time? Are you currently being treated or have you been treated for depression? Do you or have you been treated for an eating disorder? (Anorexia, bulimia, binge eating disorder, compulsive over eating?)
4 Do you snore? Do you ever wake up at night gasping for breath? Has anyone ever told you that you stop breathing while asleep? Do you exercise regularly? If so, what type of excise do you perform? How many times per week do you exercise? How long do you exercise each time? In your opinion, what contributes to your excess weight? Portion sizes Eating too much fat/sugar Nervous eating Lack of exercise Emotional Eating Compulsive Eating Stress Lack of knowledge about healthy eating and exercise
5 Medical Health Information 1. Medications Please list all prescribed and over-the-counter medications that you are currently using: MEDICATION NAME DOSE TIMES PER DAY YEAR PER DAY YEAR STARTED PURPOSE 2. Pharmacy Information Name of Pharmacy Phone Number
6 3. Surgical Information Type of Surgery Year Have you or a family member ever had any trouble with anesthesia? If yes, please explain what occurred 4. Medical History Please indicate if any of the following conditions have ever been significant problems for you. Please specify the year diagnosed and the physician who currently manages the problem. Cardiac: Coronary Artery Disease Year Diagnosed Physician MI (Heart Attack) Year Diagnosed Physician If yes, treatment High Cholesterol/Triglyceride Year Diagnosed Physician Chest Pain Year Diagnosed Physician Congestive Heart failure Year Diagnosed Physician Valvular Heart Disease (mitral Year Diagnosed Physician valve prolapse, mitral valve regurgitation, etc.) Rheumatic Fever Year Diagnosed Physician
7 Heart Murmur Year Diagnosed Physician Irregular heart beat Year Diagnosed Physician High blood pressure Year Diagnosed Physician Pulmonary Asthma Year Diagnosed Physician Pneumonia Year Diagnosed Physician Bronchitis Year Diagnosed Physician COPD (Emphysema) Year Diagnosed Physician Tuberculosis Year Diagnosed Physician Diagnosed Sleep Apnea Year Diagnosed Physician If yes, treatment Stop breathing while sleeping Loud Snoring Gasping for Breath at Night Family History of Sleep Apnea Family Member Endocrine: Diabetes Mellitus Year Diagnosed Physician Are you currently on Insulin? Hyperthyroid Year Diagnosed Physician Hypothyroid Year Diagnosed Physician Adrenal (Cushing`s) Year Diagnosed Physician Diagnosed Sleep Apnea Year Diagnosed Physician Other Year Diagnosed Physician Cancer: Type/Organ(s) Affected: Treatment: Do you have a history of breast cancer? Year Diagnosed Physician
8 Peripheral Vascular Disease Arterial Vascular Disease Year Diagnosed Physician Pulmonary Embolism Year Diagnosed Physician DVT (Phlebitis) Year Diagnosed Physician Superficial Phlebitis Year Diagnosed Physician Swelling legs, ankles Year Diagnosed Physician Leg Ulcers Year Diagnosed Physician Do you have any Ulcers currently? Varicose Veins Year Diagnosed Physician Renal Kidney Disease Year Diagnosed Physician Urinary Stress Incontinence Year Diagnosed Physician Kidney Stones Year Diagnosed Physician Obstetric/Gynecologic: Have you ever been pregnant Please indicate the number of pregnancies to term Please indicate the number of deliveries Please indicate whether you are Premenopausal Postmenopausal Menstrual Cycles ne Irregular Polycystic Ovarian Syndrome or History Musculoskeletal: Lowe Back Pain Year Diagnosed Physician Osteoarthritis/Degenerative Joint Disease Year Diagnosed Physician If yes, Joints involved: Painful Joints (without osteoarthritis/djd): Central Nervous System: Seizures Migraines Frequent Headaches Visual disturbances Hearing Impairments Numbness of extremities Autoimmune disease (ex: Lupus, Rheumatoid Year Diagnosed Physician Arthritis, Connective Tissue, etc.) Gout Year Diagnosed Physician If yes, list joints involved Have you ever had any broken bones of the face?
9 Blood Disorders: Anemia Year Diagnosed Physician If yes, type if known Do you have or have you had any abnormalities with bleeding or clotting If yes, explain Psychiatric Disorders: Depression Are you currently receiving therapy or medications? Bipolar Disorder Have you ever been hospitalized for the above conditions? Anxiety Schizophrenia Eating Disorder Other: Social/Other History: Please complete the following questions regarding your social, personal and family history Occupation: Full Time Part Time Temporary Retired Disability- Indicate cause Highest grade or level of education 9-11 years High School Vocational/Technical Attending College Graduate Training College Graduate Graduate Degree Religious Affiliation (optional) Atheist Catholic Jewish Methodist Presbyterian Other Do you have any children? If yes, how many? Ages? Smoking/Drug Alcohol History: Do you currently use tobacco? Have you ever used tobacco? If you answered yes to the above questions:
10 What type of tobacco did you Cigarettes Cigars Pipe Chew/Snuff use? What age did you start tobacco use? How many years have you used tobacco? How much do/did you smoke ½ pack or Between 1 to Between 1 ½ to 2 packs 2 ½ packs plus per day? less 1 ½ packs If applicable, what age did you quit smoking? Do you currently drink alcohol? If you answered yes to the above question: What types of alcohol are you Wine Beer Mixed Drinks Other: drinking? How many drinks do you 1-2 month 3-4 month 5-6 month Other: currently drink? Have you ever been treated for an alcohol problem? Have you ever used any illicit drug? (Marijuana, Cocaine, Heroin, Amphetamine, etc? If yes, Please indicate what: How long ago? 6 months or less 6 months- 1 year More than 1 year Family History: Check the box if any blood relatives have had: Colon Cancer/Polyps Crohns Disease, Ulcerative Colitis Liver Disease or Hepatitis Pancreatic Cancer Gall Bladder Disease Stomach or Esophagus Cancer Diabetes Coronary Artery Disease Medical information about your biological family (i.e., ages, medical conditions, types of cancer, etc.): Father: Mother: Siblings: Children: Paternal Grandparents: Maternal Grandparents:
11 4. Previous Diagnostic Procedures Please list any laboratory diagnostic procedures within the last year. Please indicate what month they were performed. EKG Echocardiogram Heart Upper GI Catheterization Upper Endoscopy Abdominal Sonogram Sleep Study Pulmonary Function Test: CT Scan Other: 6 months- 1 year More than 1 year Stress test Lower GI Colonoscopy Chest X-ray Please list any specific question(s) that you may have about your surgical procedures in order that our doctor may become aware of your concerns priort to your appointment with us.
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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 8
llpage Age: Name: DOB:----- Date: MRN: Weight Loss Surgery Follow-Up Data Height Weight LB WL BMI EBW %EWL
Name:------------ DOB:----- Age: MRN: 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
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Patient Name: MR: Date: Name DOB / / Age Marital Status Race Gender M / F Height Present Weight Usual Weight Insurance Managed Care Self referral Yes No Yes No Yes No Primary Care Physician Referring Physician
PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
Sleep Symptoms & History
Sleep Symptoms & History In your own words, please tell us what brings you to the sleep clinic today? How long have you been experiencing your sleep problems? yrs. mos. To give us a precise understanding
New Patient Intake Form
New Patient Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes,
Anesthesia Preoperative Patient History
Anesthesia Preoperative Patient History Please Complete and BRING WITH YOU to Your Anesthesia Appointment Patient Name: Date of Birth: Phone Number: Kind of Surgery You are Having: Date of Your Surgery:
Bariatric Surgery. Website: http//baybariatricsurgery.com
Bay Bariatric Surgery Kevin L. Huguet, M.D. General Surgery Laparoscopic Surgery Bariatric Surgery George Rossidis, M.D. General Surgery Minimally Invasive Surgery Bariatric Surgery Website: http//baybariatricsurgery.com
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Psychiatric Evaluation Intake Form
Patient Contact Information Psychiatric Evaluation Intake Form Patient Name: Date of Birth: Age: Last First MI Address: Contact phone number: Email address: Emergency Contact/Number/Relationship: Primary
SURGERY SPECIALTY PATIENT HEALTH HISTORY
SURGERY SPECIALTY 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?