Nebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY

Transcription

1 Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable exercise that uncovers clues as to how your weight has changed over time and what may have had an effect on your weight. We have provided a sample of what this graph may look like, and you are free to provide as much detail in your timeline as you wish. Do not worry about being exact in every detail. This gives you a general overview about how your weight has changed with major events in your life v1 (5/16) Page 1 of 10

2 MEDICAL HISTORY Name MY WEIGHT TIMELINE v1 (5/16) Page 2 of 10

3 Nutrition We would like to have a general idea about your diet. Answer the following questions focusing on what a normal day for you has been in the last several months. What percentage of the time do you eat: Breakfast 0% 25% 50% 75% 100% Lunch Supper What do you typically eat for: Breakfast Lunch Supper Who does the cooking in your home? Who does the grocery shopping? What time of day do you find yourself snacking? How many meals a week do you eat out? What is your normal intake daily of the following (i.e., 1 can of soda = 12 ounces): Soda Coffee Tea Juice Water Energy drinks Alcohol (any type) v1 (5/16) Page 3 of 10

4 Please check the appropriate number or response. In the past three months: ne Slightly Moderately Extremely 1. Have you felt fat? Have you had a fear that you might gain weight or become fat? 3. Has your weight influenced how you see yourself as a person? 4. Has your shape influenced how you think about yourself? During the last six months have there been times when you felt you have eaten what other people would regard as an unusually large amount of food (e.g., a quart of ice cream)? 6. During times when you ate an unusually large amount of food, did you experience a loss of control or feel as though you could not stop eating or control what or how much you were eating? 7. How many days per week on average, over the last six months, have you eaten an unusually large amount of food and experienced a loss of control? How many times per week on average, over the last three months, have you eaten an unusually large amount of food and experienced a loss of control? During these episodes of overeating and loss of control did you: 9. Eat much more rapidly than normal? 10. Eat until you felt uncomfortably full? 11. Eat large amounts of food when you did not feel physically hungry? 12. Eat alone as you were embarrassed by how much you were eating? 13. Feel disgusted, depressed, or guilty about overeating? 14. Feel very upset about your uncontrollable overeating or weight gain? 15. How many times, per week on average over the last three months have you made yourself vomit to prevent weight gain or counteract the effects of eating? How many times, per week on average over the last three months have you used laxatives or diuretics to prevent weight gain or counteract the effects of eating? How many times, per week on average over the last three months have you fasted (skipped at least two meals in a row) to prevent weight gain or counteract the effects of eating? How many times, per week on average over the last three months have you engaged in excessive exercise specifically to counteract the effects of overeating episodes? Have you been taking birth control pills or shots over the last three months? v1 (5/16) Page 4 of 10

5 Review your past weight loss attempts. Type of Program Year Results (# lbs, gain/loss) Are you interested in bariatric surgery? PHYSICAL ACTIVITY Do you have a regular exercise activity? If yes, describe the activity. What type of activity is involved in your job? Does knee pain limit your activity? Does hip pain limit your activity? Does foot pain limit your activity? Does shortness of breath limit you? How many hours total do you sit watching TV or using a computer daily? What physical activity have you enjoyed in the past? What type of exercise would you like to do? Current weight Current height Current BMI (if known) DEMOGRAPHICS v1 (5/16) Page 5 of 10

6 How many hours of sleep do you get on average? SLEEP What are the normal times you try to go to sleep and awaken? Have you ever been diagnosed with sleep apnea?, Year If yes, what treatment was prescribed? Are you still using that treatment? Have you ever had an overnight sleep study? What were those results? What shift or what time of day do you work? How many times do you get up to go to the bathroom from sleep? Do you have trouble falling asleep? Do you have trouble staying asleep? Do you take medications to fall asleep? Do you ever wake up with headaches? Do you snore on most nights? Have you been told your snoring is loud? Have you ever been known to stop breathing or Never Occasionally Frequently gasping during sleep? Do you occasionally fall asleep during the day when: You are busy or active? You are driving or stopped at a light? Do you often feel tired, fatigued, or sleepy during the daytime? Do you get up and eat after going to bed? SOCIAL HISTORY Marital Status: Single Married Divorced Widowed Significant Other How many people live in your house? Educational Level: Grade School High School College Post-Graduate Do you work? If yes, what type of work? Hours worked? Do you smoke? If yes, how many packs a day? If you chew tobacco, how long does a can last? If you used to smoke or chew, when did you quit? Do you presently drink alcohol? If yes, how many days a week do you drink? How many drinks per day on average? Do you ever drink more than six drinks a day? Do you presently use any illicit drugs? Do you have a history of drug addiction? v1 (5/16) Page 6 of 10

7 METABOLIC AND ENDOCRINE HISTORY Have you ever been diagnosed with diabetes or had high blood sugars? Have you ever had skin growths removed from your neck? Are you ever extremely thirsty or go to the bathroom frequently? Females: Did you have diabetes during pregnancy? Do you have a history of thyroid problems? Males Do you have a problem with low sexual desire? Do you have difficulty achieving an erection? Females Do you have a history of infrequent menstrual cycles? PSYCHIATRIC HISTORY Have you ever been diagnosed or treated for depression? If yes, can you recall what medications you were on? Please list below: Have you ever been diagnosed or treated for anxiety? If yes, can you recall what medications you were on? Please list below: Have you had suicidal thoughts recently? When? Have you ever attempted suicide? When? Do you have a history of sexual abuse or molestation? Do you have problems with concentration or attention? Have you ever been treated for an eating disorder? When? v1 (5/16) Page 7 of 10

8 PAST MEDICAL HISTORY Operations Illnesses Allergies Medications Foods Environmental Present Medications and Dose Vitamins/Supplements/Over-the-Counter Medications FAMILY HISTORY Father Mother Brother Brother Brother Brother Sister Sister Sister Sister Age Medical Problems Overweight Alive v1 (5/16) Page 8 of 10

9 QUALITY OF LIFE SCALE Please read each item and check the number that best describes how satisfied you are at this time. Please answer each item even if you do not currently participate in an activity or have a relationship. You can be satisfied or dissatisfied with not doing the activity or having the relationship. 1. Material comforts home, food, conveniences, financial security... Delighted Pleased Mostly Satisfied Mixed Mostly Dissatisfied Unhappy Terrible 2. Health being physically fit and vigorous Relationships with parents, siblings, and other relatives communicating, visiting, helping Having and rearing children Close relationships with spouse or significant other Close friends Helping and encouraging others, volunteering, giving advice Participating in organizations and public affairs Learning attending school, improving understanding, getting additional knowledge Understanding yourself knowing your assets and limitations knowing what life is about Work job or in home Expressing yourself creatively Socializing meeting other people, doing things, parties, etc Reading, listening to music, or observing entertainment Participating in active recreation Independence, doing for yourself... Total / v1 (5/16) Page 9 of 10

10 Could you please describe your motivation for coming to Nebraska Bariatric Medicine? Who is your primary care physician? Do you see any specialists, please list? What is the best phone number to contact you at? ( ) Thank you very much for completing this questionnaire. You can mail this form to us at 8207 rthwoods Dr., Suite 101, Lincoln, NE or fax it to us at (402) Dr Jons and his staff will review your information and request additional documentation, if needed. After we review your information we will then call you to arrange your first appointment. If you have any questions, you can contact us at (402) Please refer to our website, nebariatric.com, for more information. Thank you! We look forward to seeing you soon v1 (5/16) Page 10 of 10