Weight loss surgery. Life-changing results.
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- Chastity Hunter
- 6 years ago
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1 Weight loss surgery. Life-changing results. Our physician experts and program team is devoted to helping patients overcome obesity and reclaim the life, health and future you deserve. Minimally invasive weight loss surgeries 1-2 weeks recovery Covered by most insurance plans and Medicare 5+ years post-op education and encouragement To find out if you re a candidate for weight loss surgery, complete the enclosed information and return to to the program manager at the facility nearest you. If you have questions, call us at the locations listed. Brookwood Baptist Medical Center MBSAQIP Accredited Bariatric Center Brookwood Medical Plaza, Suite Brookwood Boulevard Birmingham, AL Program Manager: Lisa H. Griffin LisaH.Griffin@tenethealth.com phone: PRINCETON Baptist Medical Center MBSAQIP Accredited Bariatric Center Comprehensive Bariatric Center 817 Princeton Avenue POB II, Suite 120 Birmingham, AL Clinical Operations Coordinator: Kathryn Fields kat.fields@bhsala.com phone: SHELBY BAPTIST MEDICAL CENTER st Street N. Physician s Center - Room A Alabaster, AL Program Coordinator: Kaye O Neal kaye.oneal@bhsala.com phone: Weight loss surgery may be an option for adults with a body mass index (BMI) equal to or greater than 40, or equal to or greater than 35 with serious health problems related to obesity. Laparoscopic adjustable gastric banding may be an option for people with a BMI of 30 or more who have at least one serious obesity-related health problem. Weight loss surgery is considered safe, but like any surgery, it does have risks. Consult with your physician about the risks and benefits of weight loss surgery. brookwoodbaptisthealth.com/weightloss
2 SEMINAR DATE PATIENT INFORMATION LAST NAME, FIRST, MIDDLE RACE q MALE q FEMALE AGE DATE OF BIRTH STREET ADDRESS CITY, STATE, ZIP SOCIAL SECURITY # HOME /CELL PHONE WORK PHONE OCCUPATION EMPLOYER PRIMARY CARE PHYSICIAN HOW DID YOU HEAR ABOUT US? ADDRESS Responsible Party Information LAST NAME, FIRST, MIDDLE SOCIAL SECURITY # DATE OF BIRTH RELATIONSHIP TO PATIENT STREET ADDRESS CITY, STATE, ZIP HOME /CELL PHONE WORK PHONE EMPLOYER Insurance Information Insurance Name Policy # Group # Phone Policy Holder & DOB Insurance Name Policy # Group # Phone Policy Holder & DOB Insurance Name Policy # Group # Phone Policy Holder & DOB In Case Of Emergency Notify (Other Than Responsible Party) NAME ADDRESS, IF POSSIBLE PHONE PATIENT INFORMATION PACKET P. 2
3 Previous Hospitalizations/ Surgeries/Serious Illnesses Have you had a previous weight loss surgery? q Yes q No Have you or any of your family members had any type of problem with anesthesia? q Yes q No Patient Social History Marital Status q Single q Married q Separated q Divorced q Widowed Patient Lives q Alone q With Family q Other: Use of Alcohol q Never q Rarely q Moderate q Daily Use of Tobacco q Never q Previously, but quit q Current packs per day: Use of Drugs q Never q Type/Frequency: Adaptive Self-Care aids q Cane q Walker q Wheelchair q Oxygen q Other: Family Support How does your support person (family) feel about you having this type of surgery? Biopsychosocial Religion: Are there religious needs we may help you with during your hospital stay? q Yes q No Explain: Highest education level/degree earned: Family Medical History (parents, grandparents, brothers, sisters) Please indicate who has or previously had these health problems: Obesity: Lung Disease, Asthma or Emphysema: Diabetes: Kidney Disease: High Blood Pressure: Bleeding Tendency or Blood Disorder: Heart Disease (indicate what type): Breast Cancer: High Blood Cholesterol: Colon Cancer: Liver Problems: Weight History Current Height: ft. in. Current Weight: pounds What was your approximate weight for each of the past five years? Year Weight Year Weight PATIENT INFORMATION PACKET P. 3
4 Please list all diets, diet pills and diet programs that you have attempted: q COPD q Emphysema q Bronchitis: When: q Sleep Apnea q CPAP q BIPAP q Snore q Stop Breathing When and where was the sleep study done? Review of Symptoms Please indicate any personal history below: Genitourinary q Frequent Urination q Kidney Stones q Kidney Failure q Nephritis q Urinary Tract Infections Last UTI: q Incontinence or Dribbling q Pain with Urination q Leakage of urine with coughing, laughing or sneezing q On Dialysis Endocrine q Thyroid Disease When diagnosed: Medication: q Diabetes q Insulin q Oral Agent Date of onset: q Diabetic Diet Instruction Calorie Level: Respiratory q Cough/Wheezing q Shortness of breath q frequent q on exertion If you walk at a fairly good pace, how far can you walk before being out of breath? Ever hospitalized for asthma? q Yes q No On Oxygen? q Yes q No q Pulmonary embolus (blood clot in lung) Psychological q Nervousness q Anxiety q Depression Medication: q Hospitalization for emotional problem When/Where? Name of doctor treating/has treated you: PATIENT INFORMATION PACKET P. 4
5 Is your doctor aware of your interest in bariatric surgery? q Yes q No Cardiovascular q Angina q Palpitations Can you lie flat on your back? q Yes q No If no, what happens when you lie down? q Pain in neck, chest, arms q Heart Attack q Abnormal Electrocardiogram q Irregular Heartbeat q High Blood Pressure How long? Medication: q Congestive Heart Failure q High Cholesterol/Tryglicerides How long? q Blood clots in legs q Recent ECG q Pacemaker q Heart Cath Musculoskeletal q Pain/Swelling in Joints q Degenerative Joint Disease q Arthritis q Low back pain/back injury q Ankle and foot pain q Joint Replacements Which ones? q Ankle and foot pain q Fibromyalgia q Multiple Sclerosis Neurological q Stroke q Sleeping difficulty What kind? q Dizziness, Vertigo q Numbness, tingling feelings, weakness. Where? q Tremors q Convulsions/Seizures When and what caused it? q Loss of consciousness When & why? q Pseudotumor Cerebri Gastrointestinal q Indigestion q Nausea/Vomiting q Diarrhea q Constipation q GERD q Pain with bowel movement q Blood in stools q Hemorrhoids PATIENT INFORMATION PACKET P. 5
6 q Irritable Colon q Colitis q Gallbladder Disease q Gallbladder Removal q Recent Colonoscopy q Recent EGD or Scope q Ulcers q History of H.pylori q Liver problems q Hepatitis Allergies to Medications: Allergies to Food: Latex or other Allergies: What are your expectations of bariatric surgery? Other Conditions q HIV/AIDS q Bleeding Disorder q Blood Clotting Disorder q Other conditions we should be aware of? How much weight do you expect to lose? Which procedure do you prefer: q Roux-en-Y Gastric Bypass q Sleeve Gastrectomy q Lap-Band Medication Log q Medication List Added Separately Date RX Medication Dosage Frequency Are you on any blood thinners or steroids, e.g. Prednisone? q Yes Your pharmacy s name and phone number: q No PATIENT INFORMATION PACKET P. 6
7 Medical Weight Loss Progress Note NAME DATE WEIGHT BLOOD PRESSURE BMI CHANGE IN WEIGHT SINCE LAST VISIT DIAGNOSIS Diet Plan Include Notes From Diet Plan with PCP Notes q Weight Watchers q LA Weight Loss q Jenny Craig q Eat Right q Other (specify) Compliant with Diet Plan? q Yes q No Weight loss medications: Physical Activity/Exercise Plan q Gym x s wk q Walking/Running x s wk q Aerobics x s wk q Exercise Videos x s wk q Inability to Perform Recommended Modifications: Total Daily Caloric Intake: Behavior Modifications q Dietitian Consult q Group Counseling q Individual Counseling Date: Date: Date: Recommended Modifications: Comments (progress or lack of progress): Provider Signature: Date MEDICAL WEIGHT LOSS PROGRESS NOTE P. 7
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
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Spouse Information Spouse Name: Work Phone: ( ) - Emergency contact (Not living in same household) Name: Relationship: Contact Phone: ( ) -
BayChoice Surgeons Bariatric & Laparoscopic Surgery Kenneth Hollis, M.D., FACS 11914 Astoria Boulevard Ste. 125 Houston, TX 77089 Ph. 281-482-5300 Patient Information Legal Name Last: First: M.I. Birth
PATIENT INFORMATION NAME: DOB: / / AGE: FIRST MIDDLE LAST SS#: / / MALE/FEMALE RACE: MARITAL STATUS: S M W D
PATIENT INFORMATION Robert G. Marvin, M.D. The information provided in this form is vitally important in the planning of your surgical care. Omission of complete and accurate information to the physician
History of Present Illness Please answer the following questions
Last Name First Name Date of Birth: / / What is the main reason for your visit today? Social Security Number: History of Present Illness Please answer the following questions Bladder Cancer Urinary Tract
BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM
PATIENT MEDICAL HISTORY FORM Name: Date: Social Security #: DOB: Height: Weight: Email: Primary Care Physician: Referred by: Pharmacy Name/Location/Phone Number: Dialysis Center and Phone Number (if applicable):
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
NEUROLOGICAL SURGERY, P.C.
NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated
Seminar Information Page
OFFICE USE ONLY Height, Weight & BMI Insurance Primary Care Phys. Medical Problems Surgical History Med List & Dosage Allergies & Fam Hist. CDS (city, washoe, wcsd or reno diocese) OFFICE USE ONLY Pt #
PATIENT HISTORY QUESTIONNAIRE
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
ADULT INFORMATION SHEET
DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
ENT & Allergy Specialists of VA Registration Form
ENT & Allergy Specialists of VA Registration Form Which provider are you seeing today? Dr. James J. Lee Dr. Vickie K. Lee Dr. Rachel Watson Please Print Clearly Last Name PATIENT PERSONAL INFORMATION (please
Centra Weight Loss Clinic Initial Appointment Questionnaire
*Please note: To provide appropriate care, forms MUST be completed prior to your initial visit. Name Date of Birth Physician Information Referring Physician / PCP (Name) Location (city, state) Date of
Health History Questionaire
Patient DOB: Patient Name: Date: Health History Questionaire Who referred your consultation? If no one referred you, how did you hear about us? Who is your primary care physician? Have you ever seen a
Medical, Gastro-Intestinal, Social Lifestyle Information Questionnaire TODAY S DATE: / / PATIENT NAME: Gender: M / F Age:
Gender: M / F Age: Employment- ( PT / FT) Unemployed / Retired / Disabled / Occupation: Reason for visit: Race: PLEASE CHECK-OFF CAUCASIAN AFRICAN AMERICAN NATIVE AMERICAN MIDDLE EASTERN HISPANIC ASIAN