PATIENT MEDICAL HISTORY FOR B.O.L.D. (Please check the most appropriate answer. If you have any questions please call the office for assistance)
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1 Name: Date of Birth: Date: Race: Caucasion African American Hispanic Native American Pacific Islander PATIENT MEDICAL HISTORY FOR B.O.L.D. (Please check the most appropriate answer. If you have any questions please call the office for assistance) Anemia (low blood count, hemoglobin, hematocrit, or iron) Any of these symptoms in the past Any of these symptoms currently Chronic Bronchitis Yes No Chronic shortness of breath Yes No CARDIOVASCULAR DISEASE Angina Assessment (Chest Pain) No Symptoms Chest Pain only with extreme activity Chest Pain with moderate activity Chest Pain with minimal activity MD diagnosed with unstable angina Previous heart attack Congestive Heart Failure (Dr. diagnosed heart failure) or symptoms Symptoms with a great deal of activity Symptoms with ordinary activity Symptoms with minimal activity Symptoms at rest DVT/PE (Blood clot in the leg or lung) History of DVT resolved with anticoagulation Recurrent DVT long term anticoagulation Previous PE Recurrent PE, decreased function Hospitalization Vena cava filter Hypertension (high blood pressure) or symptoms Borderline, no medication MD Diagnosis of hypertension not requiring medication Treated with one medication Treated with more than one medication Poorly controlled with medication resulting in organ damage Ischemic Heart Disease (Dr. diagnosed poor circulation of the heart) Abnormal EKG History of heart attack or take medication to treat History of heart vessel surgery Active disease Lower Extremity Edema (swelling of the lower leg, ankle, or foot) Intermittent symptoms not requiring medication Symptoms require medication, elevation, or hose Leg or foot ulcers Disability, decreased function, hospitalization Peripheral Vascular Disease (Plaque build up in blood vessels outside of the heart that result in poor vessel function) No Symptoms, but doctor diagnosed bruit TIA or mini stroke diagnosed by doctor Treatment consisting of a procedure Stroke, loss of tissue related to insufficient blood flow
2 NAME: GASTROINTESTINAL Cholelithiasis (Gallstones) Gallstones present with intermittent symptoms History of gallbladder removal surgery or severe symptoms with stones Emergency gallbladder surgery required immediately prior to weight loss surgery History of gallbladder removal with ongoing unresolved complications Gastroesophageal Reflux (GERD) or symptoms Intermittent symptoms not requiring medication Intermittently require medication Take daily medication in low dose Take high dose medication Had surgery for symptoms or have been told you need to have surgery to resolve symptoms Liver (Liver Disease) Enlarged, fatty liver, with normal liver function lab values Very fatty, enlarged liver with abnormal liver lab values Mildly inflamed and fibrotic, enlarged, fatty liver Diagnosed with cirrhosis, NASH, and abnormal liver studies Failure of the liver with need for transplant GENERAL Abdominal Hernia (Dr. diagnosed hernia) Hernia present but not causing problems; no prior operation Hernia present with symptoms Hernia successfully repaired Recurrent or large hernia Chronic hernia w/complication or failed hernia repair Date of Birth Date Abdominal Skin Pannus (Belly skin folds over, resulting in skin on skin irritation) Irritation or rash caused by chafing Large overhang that interferes with walking Recurrent skin infection Surgical treatment required Functional Status (Ability to walk unassisted) No problem Able to walk 200 feet with a device such as a cane Unable to walk 200 feet with a device Require a wheelchair Bedridden Pseudo tumor cerebri (Dr. diagnosed increase in pressure caused by fluid in and around brain and spinal cord) Headaches with dizziness, nausea, and pain behind the eyes, without visual symptoms Headaches with visual symptoms controlled with diuretics Diagnosis confirmed by MRI, well controlled with diuretics Well controlled with stronger medication Require narcotics or surgical intervention Stress Urinary Incontinence (Leak urine other than when on toilet) or symptoms Minimal and intermittent Frequent, but not severe Daily, requiring a pad Disabling Operation ineffective
3 NAME: Date of Birth Date METABOLIC Glucose Metabolism (Abnormal glucose) or evidence of diabetes Elevated fasting glucose Diabetes, controlled with oral medication Diabetes controlled with insulin Diabetes controlled with insulin and oral medication Diabetes with severe complications such as retinopathy, neuropathy, renal failure, blindness Gout/Hyperuricemia (elevated uric acid in joints and bloodstream) Elevated uric acid without symptoms Elevation treated with medication Joint disease Destructive joints Disability, unable to walk Lipids (cholesterol or cholesterol elevation) No elevation in levels Elevation present, no treatment required Controlled with diet and lifestyle change Controlled with one medication Controlled with multiple medications Not controlled MUSCULOSKELETAL Back Pain (Patient reported pain in back) No treatment required for intermittent symptoms Symptoms require medication MD diagnosed degenerative changes; pain requires narcotic medication treatment Symptoms continue despite previous surgery Fibromyalgia Treated with exercise Treated with non-narcotic medications Treated with narcotics Treated with narcotics: surgical intervention either done or recommended Disabling, treatment not effective Musculoskeletal Disease (Disease of the bone and joint tissues) Pain with joint movement Symptoms treated with non narcotic medication Pain with household movements Joint surgery required History of or awaiting joint replacement PSYCHOSOCIAL Alcohol Use (How often do you drink?) Rare, on special occasions Confirmed mental health diagnosis (Psychiatrist has diagnosed you with one of the following mental disorders) Bipolar Anxiety/panic disorder Personality disorder Psychosis Depression (Sadness with loss of interest in activities previously enjoyed) Mild & episodic symptoms not requiring treatment Moderate symptoms, may require treatment Moderate symptoms that require treatment Severe symptoms requiring intensive treatment Severe symptoms requiring hospitalization
4 NAME: Psychosocial Impairment (Unable to perform basic tasks for day-to-day living due to poor ability to function socially) No problem Mild impairment in functioning, but able to perform all primary tasks Moderate impairment, but able to perform most primary tasks Moderate impairment, but able to perform some primary tasks Severe impairment, unable to perform most primary tasks Severe impairment in functioning and unable to function Substance Abuse (Use of prescription or illegal drugs in a manner other than prescribed) Rare Tobacco Use (cigarette, cigar, or pipe smoking, chewing tobacco, etc.) Rarely PULMONARY Asthma (Doctor diagnosed asthma) No medication needed for mild symptoms Symptoms controlled with inhaler Symptoms controlled with daily medication Symptoms not well controlled; use of steroids Symptoms required hospital admission or use of ventilator Date of Birth Date Obesity Hypoventilation Syndrome (low oxygen and high carbon dioxide levels resulting in breathlessness) Extremely low oxygen levels or high carbon dioxide levels Pulmonary hypertension doctor diagnosed Right heart failure Right hear failure with left heart malfunction Obstructive Sleep Apnea (Stop breathing while sleeping; diagnosed with a sleep study) Symptoms without sleep study or with negative sleep study Doctor diagnosed sleep apnea, but no CPAP or BIPAP is used to treat Use an appliance such as CPAP or BIPAP Use oxygen for low oxygen levels and diagnosis of sleep apnea Complications of sleep apnea such as pulmonary hypertension Pulmonary Hypertension (Dr. diagnosed high blood pressure in the pulmonary artery that supplies the lung with oxygenated blood) Symptoms of fatigue, shortness of breath, dizziness, and fainting Confirmed diagnosis by physician Disease controlled on medication Use of strong medications and possibly oxygen History of lung transplant or awaiting transplant REPRODUCTIVE Menstrual Irregularities (Periods that are absent or vary from the 28-day cycle) Irregular periods Heavy, prolonged periods No period Prior total hysterectomy
5 NAME: Date of Birth Date Polycystic Ovarian Syndrome (Dr. diagnosed hormonal imbalance w/numerous symptoms such as irregular periods, weight gain, acne, etc.) or symptoms Symptoms but no treatment Symptoms treated with oral birth control pills or anti-androgen medications Symptoms treated with Metformin or TZD Symptoms treated with combination therapy Infertility With my signature below, I certify that the above information is true and correct to the best of my knowledge: Signature Date
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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
MEDICAL WEIGHT LOSS PROGRAM. Medical History Form
MEDICAL WEIGHT LOSS PROGRAM 300 Gatewood Avenue, High Point, NC 27262 Phone: 336-905-6390 Fax: 336-905-6391 http://www.highpointregional.com Medical History Form Please Print: Patient Name: Date of Birth:
PeaceHealth Southwest Weight Loss Surgery Process
PHSW Weight Loss Surgery Center PHSW Specialty Clinic 8716 E Mill Plain Blvd. Vancouver, WA 98664 Phone (360) 514-4265 Fax (360)514-4233 PeaceHealth Southwest Weight Loss Surgery Process What is the next
Date of Birth: City: State: Zip: Home phone: Who is your primary care physician?
PERSONAL INFORMATION Name: Address: Date of Birth: Mobile phone: City: State: Zip: Home phone: Email: Who is your primary care physician? Phone: How did you hear about The Nebraska Medical Center Bariatrics
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?