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1 Intake Form Center for Bariatrics Patient Name Today s Date Age Date of Birth Phone Contact Person(s) This information is vital to us if we need to contact you urgently. Occasionally people move or have new phone numbers and do not notify our office. Next of kin: (Not living with you) Name Relationship Address Phone (H) ( ) (W) ( ) (C)( ) Physicians: Referring Physician Primary Care Physician Cardiologist (heart doctor) Pulmonologist (lung doctor) Endocrinologist Orthopedic Surgeon Psychologist Psychiatrist Other physician(s): Physician Physician Page 1 of 12
2 Weight and weight loss history: Height: ft. in. Weight: lbs. Age of obesity onset: 0-2 years old years old Pregnancy 2-12 years old Young adult Middle age How many years have you been at your present weight? Five year weight history: YEAR WEIGHT (pounds) Have you ever had an eating disorder? Anorexia Nervosa Bulimia Are you a sweets eater? Page 2 of 12
3 Please complete the following diet history: NAME OF PROGRAM Weight Watchers Nutrisystem Atkins Diet Center Jenny Craig OPTIFAST Slim-Fast Herbal Diet TOPS Richard Simmons Low fat Cabbage soup diet American Heart Association diet Dexatrim Sibutramine (Meridia) Orlistat (Xenical, Alli) Phentermine (Ionamin, Adipex) Phentermine/Fenfluoramine (Phen/Fen) Other: Other: YEAR & LENGTH OF PARTICIPATION WEIGHT LOSS What kind of exercise can you do: Details of any other weight loss measures (including surgical): Page 3 of 12
4 Past medical history: List all hospitalizations and illnesses for which you have been treated, e.g. diabetes, hypertension, heart disease, lung disorders, etc.) Medical history: Do you have any of the following conditions? (please check) Diabetes No Yes (complete section below) Hypertension No Yes (complete section below) Sleep apnea No Yes (complete section below) GERD (reflux disease) No Yes (complete section below) Cancer No Yes (complete section below) Arthritis No Yes Joint pain No Yes Urinary incontinence No Yes Elevated cholesterol No Yes Anemia No Yes Osteoporosis No Yes Diabetes If you have been diagnosed with or treated for diabetes, please complete the following section: Juvenile onset No Yes Year diagnosed Adult onset No Yes Year diagnosed Current form of control: Diet control only No Yes Oral hypoglycemics No Yes Insulin No Yes Number of injections per day Do you have glycosylated hemoglobin (HgA1c) levels tested? No Yes If yes, what is your level (if you know) Page 4 of 12
5 Hypertension If you have hypertension, please complete the following section: How long have you had hypertension? Are you taking medication for hypertension? No Yes # of meds Sleep Apnea If you have sleep apnea, please complete the following section: When were you diagnosed with sleep apnea? Do you use CPAP? No Yes (what settings?) Do you use BiPAP? No Yes (what settings?) GERD If you have GERD, please complete the following section: Do you have reflux during the day? No Yes If yes, how often? Many times per day Every day Most days Most weeks Occasionally Do you suffer from heartburn/indigestion during the night? No Yes If yes, how often? Many times per night Every night Most nights Most weeks Occasionally Does food or fluid reflux in the mouth? No Yes Do you vomit with reflux? No Yes Treatments you may use for reflux, heartburn, or indigestion, either prescribed or over the counter. Check all that apply. Zantac Tagamet Pepcid Prevacid Nexium Prilosec Surgery Cancer If you have been treated for cancer, please check all that apply: Breast Endometrial Prostate Colon Thyroid Skin Blood Other (name) Year diagnosed Cancer free for years Treatment (check all that apply): Surgery Chemotherapy Radiation Medication Page 5 of 12
6 Past surgical history: Any problems with anesthesia? No Yes If yes, please describe: Have you had a previous blood transfusion? No Yes If yes, date reason Have you had a transfusion reaction? No Yes If yes, describe Will you accept blood products in an emergency? No Yes Current medications: DRUG DOSE FREQUENCY Page 6 of 12
7 Allergies and adverse reactions: Include x-ray dye, antibiotics, skin preps, latex, pain medications, if applicable. Latex allergy screening questionnaire: Do you have an allergy to any latex products? No Yes Have you experienced local swelling, itching, or dermatitis associated with latex contact? No Yes Do you have a history of wheel or blister formation on contact with latex products No Yes Have you had an allergic reaction to tape? No Yes Have you had any food allergies? No Yes If yes, list here: Family history: FAMILY MEMBER ALIVE OR DECEASED AGE HEALTH PROBLEMS AND/OR CAUSE OF DEATH Father Mother Sibling Sibling Sibling Is there a family history of morbid obesity? Page 7 of 12
8 Social history: Check all that apply. Marital Status: Single Married Divorced since Widowed since Number of children: Living Will: No Yes Tobacco use: None Use smokeless tobacco Currently smoke PPD for years Previously smoked PPD for years, stopped in Alcohol: None Minimal Moderate Heavy Previously heavy Caffeine: None Minimal Moderate Heavy Drug Use: Marijuana Cocaine Crack Heroin Other (please list): Occupation: If you are unemployed, how long? What is your functional status? Independent Partially dependent Dependent Are you currently disabled or on disability? No Yes If so, how long? Review of systems: Please check yes or no for each question. General Are you currently pregnant? No Yes Have you had any surgery in the past 20 days? No Yes Gastrointestinal Do you have any liver disease? No Yes Have you had any yellow color to your eyes/skin? No Yes Have you had trouble with your gallbladder? No Yes Have you had any abdominal pain recently? No Yes Have you had any rectal bleeding recently? No Yes Cardiac Do you have irregular heart beats? No Yes Do you have a heart valve abnormality? No Yes Do you have a pacemaker? No Yes Have you ever had congestive heart failure? No Yes Have you ever had a heart attack (MI)? No Yes Have you had previous heart surgery? No Yes Have you had an angioplasty or stent placement? No Yes Have you had any chest pain or angina in the past 30 days? No Yes Page 8 of 12
9 Results of previous cardiac testing: Have you ever had an EKG? No Yes If yes, what were the results? Normal Abnormal Further testing required Have you ever had a stress test? No Yes If yes, what were the results? Normal Abnormal Further testing required Have you ever had an echocardiogram? No Yes If yes, what were the results? Normal Abnormal Further testing required Have you ever had cardiac catheterization? No Yes If yes, what were the results? Normal Abnormal Further testing required Pulmonary Do you have any history of severe emphysema? No Yes Do you have any history of severe bronchitis? No Yes Do you have any history of severe COPD? No Yes Do you have asthma? No Yes Are you using supplemental oxygen? No Yes Do you have shortness of breath at rest? No Yes Do you have shortness of breath on exertion? No Yes Do you have a history of pulmonary embolism? No Yes Vascular Have you had a previous amputation? No Yes Have you had bypass surgery in a leg? No Yes Do you have pain in your legs at rest? No Yes Are you on dialysis for renal failure? No Yes Have you ever had a deep venous thrombosis (DVT) that required treatment? No Yes Do you have renal insufficiency? No Yes Do you have venous stasis? No Yes Do you have varicose veins? No Yes Musculoskeletal Do you have any bone or joint problems? No Yes Do you have arthritis? No Yes Do you have chronic back problems? No Yes Do you have fibromyalgia? No Yes Is your ability to walk limited? No Yes Central Nervous System Do you have any paralysis or partial paralysis of legs/arms? No Yes Do you have a history of TIA s or mini-strokes? No Yes Do you have any history of CVA (stroke)? No Yes Do you have any history of seizures? No Yes Page 9 of 12
10 Skin Do you have rashes? No Yes Do you have psoriasis? No Yes Do you have non-healing lesions? No Yes Do you have any history of melanoma? No Yes Do you have any history of other skin cancers? No Yes Do you have any open wounds? No Yes Emotional Do you have anxiety? No Yes Do you have depression? No Yes Are you undergoing psychiatric therapy? No Yes Endocrine Do you have any history of thyroid disorder? No Yes Do you have any history of heat or cold intolerance? No Yes Are you taking thyroid medication? No Yes Do you have any history of an adrenal disorder? No Yes Do you have any history of a pituitary disorder? No Yes Do you take any steroids or immunosuppressants for a chronic condition? No Yes Hematologic/Lymphatic Do you have any history of anemia? No Yes Do you bruise easily? No Yes Do you have any history of excessive bleeding? No Yes Have you had a blood transfusion in the last six months? No Yes Do you have any history of leukemia or lymphoma? No Yes Do you have sickle cell? No Yes Are you on medication for anti-coagulation? No Yes Infectious Are you HIV positive? No Yes Do you have any history of hepatitis? No Yes If yes, what type? A B C Do you have any history of staph infection? No Yes Do you have any history of MRSA or ORSA? No Yes Breasts Do you have a personal history of breast cancer? No Yes Do you have a current abnormal mammogram or sonogram? No Yes When was your last mammogram? Are you overdue for mammogram? No Yes Page 10 of 12
11 Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations? This survey refers to your usual way of life today. Even if you have not done some of these things recently, try to imagine how you would have been affected. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing ACTIVITY SCORE Sitting and reading Watching TV Sitting, inactive, in a public place (e.g. movie theater) As a passenger in a car for an hour with no break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch with alcohol Sitting quietly after lunch with no alcohol In a car, while stopped for a few minutes in traffic TOTAL Page 11 of 12
12 I attended the Baptist Center for Bariatrics informational seminar on / / Patient s signature Date You may wish for Baptist Center for Bariatrics to discuss your confidential information with others (such as spouse, partner, family member, etc.). We need your permission to do this. I DO NOT authorize Baptist Center for Bariatrics to discuss my confidential information. I DO authorize Baptist Center for Bariatrics to discuss my confidential information with: Name Relationship Name Relationship Name Relationship Patient s signature Date PLEASE COMPLETE THIS FORM AND EITHER BRING IT TO YOUR STEP 2 OFFICE VISIT OR RETURN IT PRIOR TO YOUR VISIT BY FAX: Fax: , ATTN: Bariatric Coordinator Questions? Call Center for Bariatrics baptistbariatrics.com Page 12 of 12 09/2015
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PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Bariatric Questionnaire
Bariatric Questionnaire The information you provide will help us to plan your treatment, please carefully fill out and sign the last page. PERSONAL DETAILS Hospital Desired: Desired Medical Procedure:
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON SURGERY 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?
Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305
Patient Information Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305 Home Phone: Cell Phone: Last Name: First Name: MI Mailing Address: APT City/State/Zip Sex: Male Female Birthdate:
SLEEP SCREENING QUESTIONNAIRE
Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
EMORY SLEEP CENTER Sleep and Health Questionnaire
EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City/State/Zip: Preferred Contact Number: Work Home Cell Occupation:
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS NPSG CPAP CPAP Retitration Split Night PATIENT INFORMATION: Name: Last First Middle Initial Address: City: State: Zip: Social Security #: DOB: Gender: Age: Phone Number: Cell: Work:
Bariatric & Laparoscopy Center
Dr. Muhammad Jawad and Dr. Andre Texieria Follow the steps to get started on your weight loss journey! Step # 1 Call 800 number on back of your insurance & card ask if the procedure code below is a covered
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
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
Gender: Male Female Age: Current Address: City: State: Zip Code: Work Phone: Is it okay to leave a message? VISIT INFORMATION
SIENA PROACTIVE INTERNAL MEDICINE DR. DEBORAH BLENNER 45 Terry Road, Suite B Smithtown, NY 11787 www.sienaproactive.com Phone: (631) 656-8171 Fax: (631) 656-8173 PATIENT INFORMATION Last Name: First Name:
Surgical History Please list all operations and dates:
1 General Information *Please complete in blue or black ink only* Name: Date: Address: City: State: Zip Code: Date of Birth: Email: Telephone: (Cell) (Home) (Work) Referred by: Occupation: Primary Doctor:
Michel K. Stephan, M.D., F.A.C.S. Bariatric SOUTHWESTERN MEDICAL CENTER. Patient Bariatric Questionaire Bariatric Patient Questionnaire
Patient Questionnaire Patient Questionaire 40001234 Name: Sex: M F Age: Street Address: City/State/Zip: Home Phone:( ) Work Phone: ( ) Cell/Other:( ) Weight: Height: Date of Birth: Previous attempts at
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Patient History Form: Bariatric Surgery Page 1 of 9
Date you attended Informational Session / / How did you hear about us? Radio Newspaper TV Word of Mouth Magazine Referred by Dr. Other: Name: Age: Date of Birth: / / Occupation: Gender: Male/Female Address:
Address: City: State: Zip code: Mobile Phone: ( ) - Alternate Phone: ( ) - Employer: ID#: Group#: Policyholder (Subscriber Name): Relationship:
Please complete and mail, fax, or e-mail to: Meg El Haoud, RN Bariatric Program Coordinator 788 8th Ave. SE Level 3, Suite 300 Cedar Rapids, IA. 52401 Fax: (319) 398-6748 Phone: (319) 398-6747 melhaoud@mercycare.org
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
Pre-Test Questionnaire. Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over
Pre-Test Questionnaire Date: Hospital # (Please Print) Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over Chief Complaints What problem(s) brings you to sleep disorders
PATIENT HEALTH INFORMATION SHEET
. Norman J. Brodsky, M.D. Board Certified Michael D. Gauwitz, M.D. Diplomate, ABR Taghrid A. Altoos, M.D. Radiation Oncology Hiral K. Shah, M.D. PATIENT HEALTH INFORMATION SHEET NAME: DATE OF BIRTH: AGE:
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE *Please bring copies of any recent Blood Work and Physician Sleep Referral Order* Please answer every question to the best of your