Fairfield County Bariatrics & Surgical Specialists, P.C. Neil R. Floch, M.D. Abraham Fridman, D.O. Craig L. Floch, M.D.
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1 Fairfield County Bariatrics & Surgical Specialists, P.C. Neil R. Floch, M.D. Abraham Fridman, D.O. Craig L. Floch, M.D. 148 East Avenue, Suite 3-A 2 Trap Falls Road, Suite 100 Norwalk, CT Shelton, CT (203) (203) Reflux Surgery Program Questionnaire Name: Date of Birth: Race: Address: Phone Number: (Home) (Cell/Work) Please provide your Primary Care Physician s information : Physician s Name: Physician s Address: Phone Number: Please provide your Gastroenterologist s information: Physician s Name: Physician s Address: Phone Number:
2 Please circle the following if you are currently or have experienced any of these symptoms: Please Rate Severity 1-3 1= monthly or less 2= weekly 3= everyday Heartburn Dysphagia Reflux Regurgita on Odontophagia Nausea Vomi ng Abdominal Pain Bloa ng Belching Bile in Mouth Diarrhea Loss of Appe te Gas/Flatulence Afraid to Eat Get Full Quick Difficulty Sleeping How long have you suffered from reflux? What was your first symptom(s)? What was your worst symptom(s)? Do these symptoms occur while on medication? Yes No What medications have you taken in the past? Have they controlled your symptoms? Are you currently or have you been under the care of another physician for this? Yes No If yes, please provide that information:
3 Have you had any diagnostic testing done for these conditions? Yes No Please indicate below if you had the testing and if so where it was done: Upper Endoscopy Manometry Motility 24 Hour ph test Gastric Emptying Study Other than the symptoms described in the previous page, have you experienced any of these secondary symptoms? Please indicate below Please Rate Severity 1-3 1= monthly or less 2= weekly 3= everyday Chest Pain/Angina Sore Throat Choking Asthma Difficulty Breathing Wheezing Wheezing Coughing Forced Vomi ng Hoarseness Dental Erosion Do these problems effect your sleep? If yes, how so? Are these symptoms associated with eating? Do specific foods trigger reflux? How long after a meal do you experience these symptoms?
4 What do you take to make it feel better? Have you tried prescription or over the counter medication? If so, please indicate which medication and what dosage. Medical History Do you have or have you had any of the following in the past: Heart Disease: Yes No Chest Pain/Angina Heart A ack, how many events Coronary Artery Disease Coronary Heart Failure Arrhythmia Atrial Fibrilla on Pacemaker Pulmonary Embolism (blood clot in lung) High Blood Pressure CVA (stroke) Venous Insufficiency (varicose veins): Yes No Thrombophlebi s: Yes No Breathing Problems: Yes No Asthma Shortness of Breath COPD Emphysema Other: Sleep Problems: Yes No Sleep Apnea Snoring Other:
5 Diabetes: Yes No If yes, how long: Diet Controlled Medica on Controlled Insulin Dependent Gesta onal Diabetes (pregnancy related) Thyroid Issues: Yes No If yes, please specify: Arthritis: Yes No Osteoarthritis Rheumatoid Arthritis Gastrointestinal Issues: Yes Hiatal Hernia Ulcers Gallstones Pancreatitis Infected Gallbladder Fatty Liver Hepatitis No Cancer: Yes No If yes, please specify: Are you currently receiving treatment or in remission? Current Medications (Please indicate dose and frequency of each medication): Allergies and Intolerances (Please indicate allergen and reaction):
6 Surgical History Please check all that apply: C-Section Tonsillectomy Appendectomy Gallbladder Surgery Ventral Hernia Repair Umbilical Hernia Repair Carpal Tunnel Repair Orthopedic Surgery Repair Cosmetic Surgery Other: Other: Other: Social History Marital Status: Single Married Divorced Widowed Do you drink alcohol? Yes No If yes, how many drinks per day/week? Do you smoke cigarettes? Yes No If yes, how many packs per day? How many years have you smoked? If you have quit, how long ago did you stop? If you have quit, how many years did you smoke? This Section to be Completed by Physician: Review of Systems: Head: Neck: Heart: Lungs: GU: GI: Ortho: Skin: Diagnostic Testing: EGD UGI Manometry/Motility 24 ph Gastric Emptying Study Treatment Plan/Next Steps:
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:
Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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Salt Lake Orthopaedic Clinic Initial Visit Form
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GUPTA SPORTS & SPINE CENTER
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Patient Name Date of Birth Age. Other phone ( ) . Other
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NEW PATIENT QUESTIONNAIRE
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Bariatric Surgery Program Patient Health Questionnaire. This form must be completed and returned at your Bariatric Education Class.
The Center for Weight Loss Surgery 111 Osborne Street Danbury, CT, 06810 203.739.7131 / 203.739.1669 fax Bariatric Surgery Program Patient Health Questionnaire Name: DOB: Please answer the following questions
Advanced Laparoscopic Specialists Minimally Invasive and Bariatric Surgery
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Page 1 of 5 Physicians: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Physicians: Samuel J. Tarwater, MD Travis J. Rutland, MD Ashwani Kapoor, MD Pathologist:
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
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Page 1 of 5 Gastroenterologists: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Samuel J. Tarwater, MD Travis J. Rutland, MD Gastroenterologists: Marc L.
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Patient Medical History
Date: The PMA Metabolic and Bariatric Weight Management Center 410 West Linfield-Trappe Road, Suite 100 Limerick, PA 19468 (610) 495-2338 Patient Medical History Name: Date of Birth: Age: Female Male ALLERGIES:
PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
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