Patient History Form: Bariatric Surgery Page 1 of 9

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1 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: Phone Number: - - May we leave a message? Yes No Best time to call: Which surgery do you wish to have? Roux-en-Y Gastric Bypass Lap Band Revision of Prior Bariatric Surgery Actual Body Weight Height BMI (Body Mass Index) Goal Weight Your Measurements Weight History Please estimate as closely as possible for all that apply. Birth Weight Start of High School High School Graduation Lowest Adult Weight Highest Adult Weight Marriage In your own words please describes how the surgery works, the risks associated with having surgery, and the changes that you will have to make to your life after surgery. Patient History Form: Bariatric Surgery Page 1 of 9

2 In your own words explain why you want this surgery, and how you feel it will help you. Dietary History Approximate age when you first started seriously dieting. Diet Type Yes/No Dates Duration MD Weight Lost Supervised Jenny Craig Y/N Y/N Nutri System Y/N Y/N Weight Watchers Y/N Y/N Opti Fast Y/N Y/N Medi Fast Y/N Y/N Fen/Phen Y/N Y/N Redux Y/N Y/N Meridia Y/N Y/N Xenical Y/N Y/N OTC Diet Pills Y/N Y/N T.O.P.S Y/N Y/N Curves Y/N Y/N O.A. Y/N Y/N Metabolife Y/N Y/N Acupuncture Y/N Y/N Hypnosis Y/N Y/N Atkins Diet Y/N Y/N Work w/dietician Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N For Female Patients Only Pregnancy #1 Year Weight at Start at delivery Pregnancy #2 Year Weight at Start at delivery Pregnancy #3 Year Weight at Start at delivery Pregnancy #4 Year Weight at Start at delivery Number of pregnancies: Number of live births: Miscarriages: Abortions: Obstetric Complications: Plan to have more children: Yes No Patient History Form: Bariatric Surgery Page 2 of 9

3 Weight Related Illnesses Have you had, or do you have any of the following illnesses of symptoms? Heart Disease: Diagnosis: Year you were diagnosed Angina If Yes, what year?: M.I. (myocardial infarct) If Yes, what year?: CABG (Coronary artery bypass graft) If Yes, what year?: Abnormal EKG If Yes, what year?: Stress Test If Yes, what year?: Palpitations If Yes, what year?: High Cholesterol: If Yes, year diagnosed List medications: High Triglycerides: If Yes, year diagnosed High Blood Pressure: If Yes, year diagnosed Diabetes: If Yes, year diagnosed Type: As a result of your diabetes, do you have: Neuropathy Comments: Nephropathy (kidney problems) Comments: Asthma: If Yes, year diagnosed As a result of your asthma, in the past 2 years, have you: Visited the ER? Been hospitalized? Been prescribed steroids? How often do you experience Shortness of Breath? Please note your activity tolerance: I can walk blocks I can climb flights of stairs Other lung/ breathing problems: Diagnosis: Year you were diagnosed Sleep Apnea: If Yes, year diagnosed Treated by Dr. CPAP/BI-PAP used regularly: Last sleep study: / (month/year) Note: We will need a copy of your last sleep study if you wish to pursue surgery. Patient History Form: Bariatric Surgery Page 3 of 9

4 Heartburn: If Yes, year diagnosed Belching up acid/ reflux: If Yes, year diagnosed Diagnosed with Hernia: If Yes, type: Surgery to repair hernia? If Yes, year Surgeon: Gallbladder Disease: Gall bladder removed? If Yes, year If removed, was the surgery done with an open incision, or laparoscopically? Leakage of Urine: If Yes do you wear pads frequently? Joint Pain: Hips Knees Ankles Feet Back Have you seen a specialty doctor for these problems? List medications taken for these problems, (including over the counter medications) List any weight related injuries or trauma: Circulation problems: Comments: Edema (swelling) If Yes, location: Thick scaly skin Varicose Veins Leg ulcers If Yes, currently healed? If No, how are they being treated? Other Weight Related Problems: Comments: Patient History Form: Bariatric Surgery Page 4 of 9

5 Past Medical History Childhood Please identify the following childhood illnesses that you have had: Measles Mumps Chickenpox Obesity Heart murmur Rheumatic Fever Please identify which of the following serious illnesses you have been diagnosed with: Hepatitis AIDS/HIV Colitis Kidney Disease Bleeding disorder Thyroid disorder Irritable Bowel Rheumatoid Arthritis Multiple Sclerosis Blood Clot Sickle Cell Disease Fibromyalgia If Yes to blood clot: Where When Treatment Did your clot move to your lung? (Pulmonary Emboli) Please list below all serious illnesses and hospitalization you have experienced as an adult: Major illness Date Treatment Major Surgery Date Have you had a previous weight loss surgery? If Yes, type: Surgeon: Date: Allergies Allergic to any medications? If Yes, list each medication and your reaction: Allergic to: Surgical Tape Latex Iodine Other If Yes, list: Patient History Form: Bariatric Surgery Page 5 of 9

6 Medications Please list ALL medications that you are currently taking including vitamins, herbal supplements, and over the counter medications. Medication Name Dosage Frequency Are you in any blood thinning medication (Coumadin/Warfarin/Plavix)? Are you taking any medications that have Aspirin in them? Are you taking any non-steroidal anti-inflammatory drugs (Ibuprofen/Aleve/Advil/ Celebrex/ Motrin/ Toradol)? Social History (Habits) Do you use any form of tobacco? (smoke/chew) Are you willing to quit? Previous smoker? If Yes, frequency: If Yes, quit date: Do you use alcohol? If Yes, how often? /week Number of drinks each time Are others concerned about your alcohol use? Street Drug Use? If Yes, type of drug used: Frequency: Caffeine Use? If Yes, type: Cups/Day: Hobbies: Eating Habits: Do you use eating as an emotional outlet? Patient History Form: Bariatric Surgery Page 6 of 9

7 What is your greatest fear regarding having surgery? Family History Mother Father Maternal Grandmother Maternal Grandfather Fraternal Grandmother Fraternal Grandfather Sibling Sibling Sibling Sibling Living Current Age Age at Death Cause of Death Please indicate if there is a family history of: Obesity Kidney Disease Lung Disease, asthma, emphysema Diabetes High Blood Pressure Bleeding tendency or Blood disorder Heart Disease Breast Cancer High Cholesterol Blood Clot Colon Cancer Pulmonary Emboli (blood clot to lung) Sickle Cell Disease Physicians Please list any physicians that you are seeing: Orthopedic: Primary Care Physician: Cardiologist: Pulmonologist: Psychologist/ Psychiatrist/ Therapist Other: Patient History Form: Bariatric Surgery Page 7 of 9

8 Please completely fill out the following questionnaire. This will determine whether or not you may need to be tested for sleep apnea prior to surgery. Thank you. Have you been diagnosed with Sleep Apnea by a physician? Yes No If Yes, are you being treated for your sleep apnea with C-PAP/BiPAP?Yes No If you have not been diagnosed with Sleep Apnea, please complete the following: 1. Do you snore? 6. How often do you feel tired or Yes fatigued after your sleep? No nearly every day Do not know 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never If you snore: 2. Is your snoring? 7. During your wake time, do you Slightly louder than breathing feel tired, fatigued or not up As loud as talking to par? Louder than talking Nearly every day Very loud. Can be heard in adjacent rooms 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never 3. How often do you snore? Nearly every day 8. Have you ever nodded off 3-4 times a week or fallen asleep while driving 1-2 times a week Yes 1-2 times a month No Never or nearly never 4. Has your snoring ever bothered 9. Do you have high blood other people? pressure? Yes Yes No No Do not know 5. Has anyone noticed that you quit breathing during your sleep? Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never Patient History Form: Bariatric Surgery Page 8 of 9

9 Now that you have completed our history form please take a moment to look it over one last time to assure that all questions have been answered completely. It is very important that we have a complete understanding of your health as we help you prepare for surgery. Once you are sure that all questions are answered, please return the forms to the address below. The information can also be faxed to the fax number listed below. If while filling out this information you have any question please feel free to contact our program so that we can assist you. Helpful Numbers: Theda Clark Medical Center Bariatric Coordinator: Midwest Bariatric Solutions: (ask for Bariatrics) Midwest Bariatric Solutions website: Fax Number: Mailing Address: Attn: Midwest Bariatrics 100 Medical Plaza, Suite 400 Neenah, WI Please sign to verify that all the information you have provided is accurate to the best of your knowledge. Signature: Date / / Please read and sign the following authorization: By my signature below I am authorizing Midwest Bariatric Solutions, Theda Clark Medical Center s Bariatric Coordinator, and/or their designees to request medical information from the physicians I listed as part of this health history questionnaire on page 7. The purpose for their request of this information is so that they may coordinate my care as I pursue and investigate bariatric surgery and/or care alternatives. The types of information that they may request includes, but is not limited to: history and physical exams, discharge summaries, consultation reports, laboratory and imaging studies, clinic visits, and nutrition records. Signature: Date / / Please print your name: Updated 07/08 Patient History Form: Bariatric Surgery Page 9 of 9

Health History Form: Bariatric Surgery

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