PATIENT HISTORY QUESTIONNAIRE
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- Jasmine Nicholson
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1 PATIENT HISTORY QUESTIONNAIRE 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. If you are visually or otherwise impaired and must use an assistant, please indicate his/her name below. Your name: Date of Birth: Person assisting with this form and relationship to you: Date: Age: Height: Weight: Approximately how long have you currently been at least pounds overweight? years months Diet History Approximate age when you first dieted: List the diets and weight loss programs you have tried: Program Dates Duration MD supervised Max loss Jenny Craig Nutri Systems Weight Watchers OptiFast MediFast Fen/Phen/Redux Meridia Lindora T.O.P.S. O.A. Metabolife Atkins Pritikin Hypnosis Acupuncture Name: Please return this form to Phoebe Sumter Bariatrics/Pheobe Sumter Surgical Associates 1
2 List any other weight loss attempt(s) your physician supervised and documented: List any others diets and/or weight loss methods you ve tried: In your own words, please describe what you hope to accomplish and how you believe your life will change by losing weight: Medications: Be sure to list your correct dosages and strengths. Also include any over the counter medications, herbal and dietary supplements you take Do you take Goody/BC Powders, aspirin, NSAIDs (Motrin, Aleve, etc.) or other aspirin based products on a regular basis? Yes No. If yes, which ones and how often? Name: Please return this form to Phoebe Sumter Bariatrics/Pheobe Sumter Surgical Associates 2
3 Medical Conditions/Diseases: Have you had or do you have any of the following illnesses or conditions? If so, please briefly explain treatment you received: Heart disease: Angina Treatment: Heart Attack (MI):When: Coronary artery bypass(cabg):when: Hospital: Coronary angioplasty or stents: When: Hospital: Abnormal EKG: Treatment: Stress test Abnormal? If yes, when and where done? Palpitations/heart murmur/valve problem Treatment: Heart failure, CHF Treatment: Other: Lung/Pulmonary disease: Asthma COPD (chronic obstructive pulmonary disease) Sleep apnea If yes, CPAP or BiPAP used or recommended? What settings are used? mm water Pneumonia After surgery? yes no Gastrointestinal disease: Ulcer/bleeding ulcer Treatment: Acid reflux/gerd(gastroesphogeal reflux disease) Irritable bowel syndrome Colitis/diverticulitis Kidneys/bladder: Kidney stones Renal insufficiency/failure (chronic or acute) Urinary retention (particularly after surgery) Name: Kidneys/bladder continued: Urinary incontinence (leakage) Please return this form to Phoebe Sumter Bariatrics/Pheobe Sumter Surgical Associates 3
4 Vascular (blood, blood vessels): High blood pressure Is it well controlled? High cholesterol High triglycerides Clots in legs (DVT) Clots in lungs (pulmonary embolus) Anemia Free bleeder/hemophiliac Blood transfusion in the past Venous stasis disease/ulcers Endocrine: Diabetes mellitus Year diagnosed Oral medication? Insulin injections? Date and value of last hemoglobin A1c: Under active thyroid Nervous System: Migraine headaches Neuropathy Slipped/degenerative disk Stroke TIAs (mini strokes) Seizure disorder Muscle/Joint/Skeletal disease: Arthritis Where affected Rheumatoid arthritis Name: Muscle/Joint/Skeletal disease continued: Lupus (SLE) Gout Spine disease Degenerative joint disease Please return this form to Phoebe Sumter Bariatrics/Pheobe Sumter Surgical Associates 4
5 Fractures Fibromyalgia Infectious Disease: Staph infection Hepatitis HIV infection Tuberculosis (TB) Mental Health: Depression Bi polar Panic disorder Schizophrenia Allergies: List any drug allergies or intolerances you know of and the effect(s) they cause: Are you allergic to (circle): tape Latex iodine Other/food allergies: Surgical History: Gallbladder removal: Open(large incision)? Laparoscopic Abdominal: Orthopedic/spinal: Head/neck/throat: Name: Surgical history continued: Chest/breast: Pelvic/urinary tract: Plastic surgery: Other surgery not listed above: Please return this form to Phoebe Sumter Bariatrics/Pheobe Sumter Surgical Associates 5
6 Did you have any significant complications with any of your operations (infection, bleeding, anesthesia reaction, breathing/lung problems)? Hospitalizations: Please list any admission(s) and the approximate dates and the reasons(s) other than the surgeries listed above: Family Medical History: Please list any conditions that tend to run in your family: Did anyone in your immediate family suffer a heart attack before the age of 50? Social history: Have you ever used tobacco? Yes No What type? When did you quit? Approximately how many total years did you use tobacco? Do you use or have you ever used intravenous (IV)drugs? Do you use or have you used illegal drugs? Who resides with you in your household? Do you have any religious objections to medical treatment? Yes No If so, what? Do you drink any form of alcohol? Yes No If so, how many drinks of beer, wine or liquor have you had in the past 7 days? Past one month? Name: What do you do in life (your occupation, hobbies, recreation, etc.)? Do you have any advanced directives for healthcare? Yes No Please return this form to Phoebe Sumter Bariatrics/Pheobe Sumter Surgical Associates 6
7 Review of Systems: Please circle the symptoms or problems below that you experience on a frequent basis or have experienced in the last three to four weeks. If you are unsure, please place a question mark beside that item. Constitutional: weight gain fatigue loss of appetite weight loss night sweats fever/chills weakness Skin: rash change in size/color of mole lumps Neurologic: headache/migraine tingling/numbness seizures insomnia memory loss trouble walking change in hearing or vision weakness on one side Lungs/Breathing: short of breath at rest coughing up blood trouble breathing with exertion stop breathing during sleep dizziness wheezing chronic cough snoring Name: Review of Systems continued: Blood/Blood Vessels: easy bruising easy bleeding Bladder/Kidneys: urgent need to urinate urinary retention, especially after anesthesia bladder leaks when sneezing/laughing, etc. painful or difficult urination blood in urine recurrent infections of bladder or kidneys Please return this form to Phoebe Sumter Bariatrics/Pheobe Sumter Surgical Associates 7
8 Ears, Nose and Throat: colds chronic cough nose bleed change in voice sore throat ringing in ears trouble swallowing dentures loose teeth Heart: dizziness chest pain palpitations (rapid or fluttering heart beat) leg swelling loss of consciousness pain in legs after walking Stomach/Bowels: abdominal pain acid reflux nausea vomiting difficulty swallowing pain in abdomen after eating heartburn diarrhea constipation black, tar like stool vomiting blood change in bowel habits blood in stool Name: Muscles/Joints/Bones joint stiffness leg cramps joint pain joint swelling back pain balance problems inability to move extremity muscle pain or weakness Please return this form to Phoebe Sumter Bariatrics/Pheobe Sumter Surgical Associates 8
9 Psychiatric/Emotional high stress sleeping more/less thoughts of suicide victim of mental or physical abuse use illegal drugs or alcohol to cope with stress take no pleasure in life memory loss sadness Female Reproductive heavy or painful periods infertility irregular periods number of pregnancies # number of live births # number of miscarriages # complication of pregnancy (high blood pressure, diabetes, toxemia) date of your last normal period birth control method So that we may provide you with the best possible care, is there anything else you would like us to know about your health or situation? Please return this form to Phoebe Sumter Bariatrics/Pheobe Sumter Surgical Associates 9
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