APPLICATION DIRECTIONS

Transcription

1 APPLICATION DIRECTIONS In order for our staff at Center for Surgical Weight Management to process your application and prepare for your surgery, we must have all documents requested in the application included and completed. Avoid unnecessary delays by following these directions. 1. Please print. 2. Use black or blue ink. 3. Include an enlarged front and back copy of your insurance card(s). Please provide copies of ALL health insurance cards, even if that insurance does not cover weight loss surgery. 4. Include a copy of your driver s license/identification card. 5. Complete every page of the application. 6. Every item on the application should be answered with a yes, no or not applicable. 7. Blanks will not be accepted. 8. Explain all yes answers. 9. Provide your primary care physician s first and last name, address, phone number and fax number. 10. Please keep a copy of your application for your records. 11. While you are completing the application, please write down any questions that you have. This includes questions about the application, medical or surgical questions or questions about the program.

2 CENTER FOR SURGICAL WEIGHT MANAGEMENT *Patient History Forms. *Please fill out completely and fax to * Date: Indicate date you attended the educational seminar Height Weight BMI (Title) First Name MI Last Name Maiden Name Suffix Phone # Address Apt # City State Country Zip Code Cell # Work # Fax # Social Security # Date of Birth Age Gender Male Female Employer Address Occupation Full-time Part-time Retired Disabled Emergency Contact Phone Relationship Name of Primary Insurance Carrier Name of Secondary Insurance (if applicable) What is your current marital status? Married Single Separated Divorced Widowed Which of the following best describes your ethnic origin? Black/African-American White/Caucasian Asian/Oriental or Pacific Islander Hispanic What category best describes your Highest Grade or Level of Education? 9 to 11 years High School Graduate Vocational/Technical Training Attending College College Graduate Graduate Degree Family Health/Weight History: In this section, complete this chart to the best of your knowledge. If adopted and have no history of your biological family, place an X in this box Adopted. Please check all that apply Disease Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Morbid Obesity Diabetes Age: Diabetes Onset High Blood Pressure Stroke (age) Heart Attack (age) Cardiovascular Disease Sleep Apnea Cancer: Type (age of onset) Death: List age and cause Has one of your relatives ever had Bariatric (weight reduction) surgery? Yes No Relationship to you: Patient Last Name Date of Birth Page 1

3 Medication Information: Please list all prescribed and over-the-counter medications that you are currently using (include vitamins and herbal supplements): Prescription Medications Dose Times per Day Purpose Over-the-counter Medications Dose Times per Day Purpose Allergy Information: Please list any known allergies: What allergic reaction did you have? Pharmacy Information: Pharmacy Address Phone Number: Health Information: Cardiac: Coronary Artery Disease Yes No Year Diagnosed: Physician: (Heart Attack) Yes No Year Diagnosed: Physician: If yes, Treatment Elevated cholesterol/triglycerides Yes No Year Diagnosed: Physician: Chest Pain Yes No Year Diagnosed: Physician: Valvular Heart Disease Yes No Year Diagnosed: Physician: (e.g. Mitral Valve Prolapse, Mitral Valve Regurgitation, etc.) Rheumatic Fever Yes No Year Diagnosed: Physician: Heart Murmur Yes No Year Diagnosed: Physician: Heart Arrhythmia Yes No Year Diagnosed: Physician: (e.g. irregular heart beat) Hypertension Yes No Year Diagnosed: Physician: Did you have a stress test? Yes No When: Where: Congestive Heart Failure Yes No Year Diagnosed: Physician: Pulmonary: Asthma Yes No Year Diagnosed: Physician: Pneumonia Yes No Year Diagnosed: Physician: COPD (Emphysema) Yes No Year Diagnosed: Physician: Tuberculosis Yes No Year Diagnosed: Physician: Observed Sleep Apnea Yes No Year Diagnosed: Physician: Loud Snoring Yes No Year Diagnosed: Physician: Shortness of breath Yes No Year Diagnosed: Physician: History of respiratory infections Yes No Year Diagnosed: Physician: Diagnosed Sleep Apnea Yes No Year Diagnosed: Physician: Did you ever have Pulmonary Function Tests? Yes No When: Where: Do you use CPAP/BiPAP? Yes No Endocrine: Diabetes Mellitus Yes No Year Diagnosed: Physician: Hyperthyroid Yes No Year Diagnosed: Physician: Hypothyroid Yes No Year Diagnosed: Physician: Renal (Cushings) Yes No Year Diagnosed: Physician: Patient Last Name Date of Birth Page 2

4 Gastroenterology: Reflux Disease (Heartburn) Yes No Year Diagnosed: Physician: Peptic Ulcer Disease Yes No Year Diagnosed: Physician: Gall bladder Disease Yes No Year Diagnosed: Physician: Liver Disease Yes No Year Diagnosed: Physician: : Year Diagnosed: Physician: Cancer: Type/Organ(s) Effected: Treatment: Peripheral Vascular Disease: Arterial Vascular Disease Yes No Year Diagnosed: Physician: Pulmonary Embolism Yes No Year Diagnosed: Physician: Phlebitis Yes No Year Diagnosed: Physician: Leg or Ankle Swelling Yes No Year Diagnosed: Physician: Blood Clots Yes No Year Diagnosed: Physician: Venous Statis Yes No Year Diagnosed: Physician: Varicose Veins Yes No Year Diagnosed: Physician: Renal: Kidney Disease Yes No Year Diagnosed: Physician: Urinary Stress Incontinence Yes No Year Diagnosed: Physician: Kidney Stones Yes No Year Diagnosed: Physician: Central Nervous Systems: Seizure Disorders Yes No Year Diagnosed: Physician: CVA (Stroke) Yes No Year Diagnosed: Physician: Metabolic Disorders Yes No Year Diagnosed: Physician: Migraine Headaches Yes No Year Diagnosed: Physician: : Yes No Year Diagnosed: Physician: Orthopedic: Lower Back Pain Yes No Diagnosed Osteoarthritis/DJD If yes, joint(s) involved? Neck Shoulders Back Hips Hands/wrist Knees Ankles Feet Heels Painful Joints Neck Shoulders Back Hips Hands/wrist Knees (without Osteoarthritis/DJD) Ankles Feet Heels Gout: If yes, list of joint(s) involved: Medical Disorders: Psychiatric Disorders: Depression Yes No Year Diagnosed: Physician: Schizophrenia Yes No Year Diagnosed: Physician: Eating Disorders Yes No Year Diagnosed: Physician: If yes, what type? Suicide attempt Yes No : Yes No Year Diagnosed: Physician: Patients Physician Information: Name of Primary Care Physician: Address: Phone Number: Fax Number: Please list any Physicians you are currently seeing: Name of Physician: Address: Phone Number: Name of Physician: Address: Phone Number: Fax Number: Fax Number: Patient Last Name Date of Birth Page 3

5 Previous Surgery Information: If applicable, please indicate if your surgical procedure was done laparoscopic or an open procedure: Have you ever had previous weight loss surgery? Yes No If yes, please explain: Have you ever had any trouble with Anesthesia? Yes No If yes, please explain what occurred: Previous Medical History: Have you ever had a blood transfusion? Yes No Do you have any problems with bleeding or clotting? Yes No Have you ever had any broken bones of the face? Yes No Have you ever had any broken bones of the back/neck? Yes No Obstetrical/Gynecological: Do you have a history of breast cancer? Yes No Have you ever had a hysterectomy? Yes No If yes, please indicate whether Vaginal Abdominal Were the Ovaries removed? Yes No Have you ever had a Cesarean Section: Yes No If yes, please indicate how many Have you ever had a tubal ligation? Yes No If yes, indicate how the procedure was done Open Laparoscopic If applicable, please indicate the number of pregnancies to term Please indicate whether you are Pre-menopausal Post-Menopausal Smoking/Drug/Alcohol History: Do you currently use tobacco? Yes No Have you ever used tobacco? Yes No If you answered yes to the above questions: What type of tobacco uses? Cigarettes Cigars Pipe Chew/Snuff What age did you start tobacco use? How many years have you used tobacco? How much do/did you usually smoke per day? ½ pack or less between ½ to 1 pack between 1½ to 2 packs 2½ or more packs If applicable, what age did you quit smoking? Do you currently use alcohol? Yes No Have you ever had a problem with alcohol in the past? Yes No If yes, please indicate when and how long: If you answered yes to the above questions: What type(s) of alcohol did/are you drinking? Wine Beer Liquor Mixed Drinks Please indicate how many drinks you currently have or have drunk each day? less than or more Please indicate other drugs that you currently use: Marijuana Cocaine Heroin Amphetamines How long have you been using? less than 6 months 6 months 1 year more than 1 year Have you ever used any drugs in the past? Yes No If so, which drugs? If yes, how long ago? 6 months or less 6 months 1 year more than 1 year Patient Last Name Date of Birth Page 4

6 Have you been on a 3-6-month physician supervised diet within the last year? Yes No If yes, please provide supporting documentation. (A copy of each office visit) Please list the history of any food or liquid diets that you have tried in an attempt to lose weight over the past five years. Please be as complete as possible. *Do not leave any blanks. Please check and provide specific information for all diets that apply. Please submit documentation where applicable that supports diet attempts. Medically Supervised Diet Programs Number of Attempts When (dates) Length of Time Weight Loss Weight Regained MC/Clinic/City Medi-fast Opti-fast Fen/Phen Redux Meridia Xenical Behavior Modification Hypnosis Accupuncture Inpatient Weight Clinic Injections Diet by Registered Dietitian Non-Physician/Dietitian Supervised Diet Programs Weight Watchers Nutri-Systems Jenny Craig TOPS The Zone Diet Atkins Slim Fast The South Beach Diet The Pritikin Principle Scarsdale Miscellaneous Diets Low Calorie Low Fat High Protein Self Imposed Fasts Richard Simmons Susan Powter Herbal Life Cambridge Metabolife Mayo Clinic Diet Diet Pills Accutrim/Dexatrim Diurex Phentermine / Adipex Exercise Health Club DVD Tapes Walking Swimming/Water Exercises Patient Last Name Date of Birth Page 5

7 Bariatric Pre-Surgery Encounter Form Date: Name: Date of birth: Height: Weight: Co-morbidities ( Select ONE statement for each category that best describes you) *If you have any questions regarding this form, please ask for assistance. High Blood Pressure No indication of high blood pressure Borderline high blood pressure, no medication Diagnosis of high blood pressure, no medication Treatment with one medication Treatment with multiple medications Poorly controlled by medications, organ damage Congestive Heart Failure No indication or symptoms of congestive heart failure Symptoms with more than ordinary activity Symptoms with ordinary activity Symptoms with minimal activity Symptoms at rest Chest Pain No chest pain symptoms Chest pain with extreme exertion (running, etc.) Chest pain with moderate activity Chest pain with minimal activity or at rest Unstable chest pain Previous heart attack Peripheral Vascular Disease (PVD) No symptoms of peripheral vascular disease Diagnosis of PVD, but no symptoms Diagnosis of PVD, on medication Transient Ischemic Attack, pain at rest Procedure done for PVD Stroke or loss of body part due to PVD Lower Extremity Edema No symptoms of lower extremity edema Lower extremity edema at times, not requiring treatment Symptoms requiring treatment, diuretics, elevation, or hose Ulcers of the lower extremities Disability, decreased function, past hospitalization Diabetes No symptoms or evidence of diabetes Elevated fasting blood sugar or pre-diabetes Diabetes controlled with oral medications (pills) Lipids (Hyperlipidemia) Not present Present, no treatment required Controlled with lifestyle change (diet and exercise) Controlled with one medication Controlled with multiple medications Not controlled Gout (Hyperuricemia) No symptoms of gout Gout, no symptoms Gout requiring medications Gout causing pain in the joints Gout causing destructive joints Gout causing disability, unable to walk Sleep Apnea No symptoms of sleep apnea Sleep apnea symptoms (excessive snoring) Diagnosed sleep apnea (no oral appliance) Sleep apnea requiring an oral appliance such as CPAP Sleep apnea with hypoxia or oxygen dependent Sleep apnea with complications (pulmonary hypertension, etc.) Obesity Hypoventilation Syndrome No symptoms of obesity hypoventilation syndrome Low oxygen level on room air Severe low oxygen level Pulmonary hypertension Right heart failure Right heart failure left ventricular dysfunction Pulmonary Hypertension (PH) No symptoms of pulmonary hypertension Symptoms of PH (tiredness, shortness of breath, dizziness, fainting) Confirmed diagnosis of PH Well controlled on anticoagulants or Calcium Channel Blocker Stronger medications or oxygen required Need or have had lung transplant Abdominal Skin No symptoms

8 Diabetes controlled with insulin Diabetes controlled with oral medications and insulin Diabetes with severe complications (neuropathy, blindness) Irritation to abdominal skin folds Skin fold large enough to interfere with walking Recurrent cellulites or ulceration of skin folds Surgical treatment required Asthma No symptoms of asthma Mild symptoms, no medication Symptoms controlled with oral inhaler (such as albuterol) Well controlled with ongoing daily medication Not well controlled, requiring steroids Hospitalized within the last 2 years, history of intubation GERD No symptoms of GERD (reflux) Intermittent of variable symptoms, no medication Intermittent medication Regularly scheduled medication for reflux In need of anti-reflux surgery, or have had anti-reflux surgery Menstrual Irregularities (not PCOS) No indication of menstrual irregularities Irregular periods Heavy periods Absence of periods Prior total hysterectomy Psychosocial Impairment No impairment Mild impairment, but able to perform all primary tasks Moderate impairment, but able to perform most tasks Moderate impairment, unable to perform some tasks Severe impairment, unable to perform most tasks Severe impairment, unable to function Cholelithiasis (Gallstones) No indication of gallstones Gallstones with no symptoms Gallstones with occasional symptoms Gallstones with severe symptoms OR previously had gallbladder removed Gallstones with complications requiring immediate surgery (prior to Gastric Bypass) History of cholecystectomy (gallbladder removed) with ongoing complications not resolved Liver Disease No indication of liver disease Enlarged liver (modest), normal liver function test Depression No symptoms of depression Mild and episodic, not requiring treatment Moderate, may require treatment Moderate, requires treatment Severe, requiring intensive treatment Severe, requirement hospitalization Confirmed Mental Health Diagnosis None Bipolar disorder Anxiety/panic disorder Personality disorder Psychosis Enlarged liver (greater), abnormal liver function test Enlarged liver with mild inflammation and fibrosis Alcohol Use: None Rare Occasional Frequent Cirrhosis of the liver Liver failure, transplant needed Tobacco Use: None Rare Occasional Frequent Back Pain Substance Abuse (Prescription or Illegal) No symptoms of back pain None Rare Occasional Frequent Occasional symptoms not requiring medical treatment Symptoms requiring non-narcotic treatment Stress Urinary Incontinence Symptoms requiring narcotic treatment No symptoms Surgical intervention done for back pain or recommended Minimal and occasional Failed previous surgical intervention with existing symptoms Frequent but not severe Daily occurrence, requires sanitary pad Musculoskeletal Disease Disabling No symptoms of musculoskeletal disease Operation ineffective Pain with community ambulation Non-narcotic treatment required Pseudotumor Cerebri Pain with household ambulation No symptoms of pseudotumor Surgical intervention required (arthroscopy) Headaches with dizziness, nausea, and/or pain behind eyes Awaiting joint replacement or have had joint replacement Headaches with visual symptoms and/or controlled with diuretics MRI confirming Pseudotumor Cerebri, well controlled with diuretics Fibromyalgia Well controlled with stronger medication No indication of fibromyalgia Requires narcotics or has had (or needs) surgical intervention Treatment with exercise Treatment with non-narcotic medications Abdominal Hernia Treatment with narcotics No hernia Treatment with narcotics and surgical intervention done or Hernia with no symptoms, no prior operation recommended Hernia with symptoms Disabling, treatment not effective Successful hernia repair Recurrent hernia or size greater than 15cm Polycystic Ovarian Syndrome (Females only) Chronic evisceration through large hernia with complications or multiple failed hernia repairs No indication of Polycystic Ovarian Syndrome (PCOS) Symptoms of PCOS, no treatment OCP s or anti-androgen prescription Metformin or TZD Combination therapy Infertility Functional Status No impairment of functional status Able to walk 200 feet with assistance device (cane or crutch) Cannot walk 200 feet with assistance device Requires wheelchair

9 Sleep Apnea Assessment for Bariatric Surgery Pt. Name: Phone Number: Date: Medical/ Sleep History/Symptoms (check appropriate boxes): Excessive Sleepiness AM Headaches High Blood Pressure Snoring Insomnia Diabetes Never feel rested/ always tired Lung Disease Depression Apnea Asthma CPAP Compliance problems Epworth Sleepiness Scale: 0= would never doze 1= slight chance of dozing 2= moderate chance of dozing 3= High chance of dozing Chance of dozing Situation Sitting and reading Watching TV Sitting inactive in a public place (a theater) As a passenger in a car for an hour without a break Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Lying down to rest in the afternoon when circumstances permit Technologist s Recommendations Signs and symptoms of Sleep Apnea; recommend a split night sleep study. Diagnosed with OSA, non-compliance with CPAP; recommend a split night sleep study with BIPAP. Patient on CPAP; recommend switch to Auto-titrating PAP device. Respiratory disorders, with diagnosed OSA; recommend consult with Georgia Pulmonary Group. Additional information: Technician Signature Date:

10 AUTHORIZATION FOR RELEASE/DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby request and authorize Center for Surgical Weight Management to release records as described below for the purpose of: Continued Treatment Insurance Attorney Personal Bariatric Surgery Patient s Full Name: (print) Date of Birth: Medical Record #: Social Security #: Home Phone: Work Phone: Current Address: To release the medical/financial records checked below to: Organization: Address: Fax Number: Phone Number: by Mail by Fax to #: to communicate verbally with: to obtain copies from: This Authorization applies to the information checked below for the date(s) of service on: 2 Year Weight History Face Sheet Pathology Report 5 Year Weight History Fetal Monitor Strips Pathology Slides/Blocks Discharge Summary Reports Financial Record Physical/Occupational Therapy Notes Electrocardiogram (ECG/EKG) Laboratory Test Results (include TSH) Radiology Films Emergency Department Record Office Visit Records Radiology Reports Entire Medical Record Operative Report, please specify below Please specifically describe other required information: I understand that the information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of the information and may then no longer be protected by the federal privacy regulations. I understand that I may revoke this Authorization at any time by presenting my revocation in writing on the Gwinnett Hospital System Authorization Revocation form, except to the extent that Gwinnett Hospital System has taken action in reliance on this Authorization. I further understand that this Authorization is specific to the information checked above, for the date of services indicated, and for the purpose written above. I understand that this disclosure may include psychiatric, drug/alcohol, and/or HIV testing results, and/or AIDS related information. Gwinnett Hospital System shall not condition treatment on the receipt of this Authorization. This authorization and/or request to release information from my protected health information (PHI) is fully understood and is made voluntarily on my part and includes faxing of PHI. I understand that a photostatic or faxed copy of this authorization is as valid as the original. I further understand that this Authorization is valid for a period of one (1) year from today s date and will expire at that time unless an earlier date is written here. X Patient s or Legal Representative s Signature Today s Date If signing as legal representative for the patient, signee must complete GHS form #