BARIATRIC SURGERY PROGRAM QUESTIONNAIRE
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1 Fairfield County Bariatrics & Surgical Specialists, P.C. 148 East Avenue, Suite 3-A, Norwalk, CT Trap Falls Road, Suite 100, Shelton, CT Long Ridge Road, Stamford, CT Shaw Street, New London, CT (203) (203) Craig L. Floch, M.D., FACS, Dr. Neil R. Floch, M.D., FACS, Dr. Abraham Fridman, D.O., Maureen Kelly, PA-C BARIATRIC SURGERY PROGRAM QUESTIONNAIRE In order to provide our practice and insurance companies the maximum information to assist them in determining the medical necessity for weight reduction surgery, we ask that you complete this form and bring it with you when you come in for your initial evaluation. Please answer these questions in their entirety. Name: DOB: _ Ethnicity: Phone Number: (cell) (home/work) Learned About Our Program (please circle one): Physician Referral Family/Friend Internet Radio TV Newspaper Please provide the name of your primary care provider/ob-gyn/referring physician: Name: Phone: Weight Loss History How long have you been overweight? years/months since age What are the highest and lowest adult weights you have achieved? lbs. lbs. (highest) (lowest) Is your weight stable at this time? (please circle) Losing Maintaining Gaining When you lose weight, do you always regain it? Yes No Do you usually gain back more weight than you lost? Yes No What was the biggest loss in pounds you had? pounds How long before you gained the weight again? years/months Describe your most successful weight loss attempt. Include the length of time on the program, the type of program, and how many years ago you lost the weight. Why do you think it was successful? 1
2 In what ways was it unsuccessful? Have you participated in a commercial weight loss program? Yes No If yes, please provide the following information: Program Duration What year? Weight Loss How Long? Weight Regain Weight Watchers Jenny Craig Atkins Medifast/Optifast Health Spa Exercise Program Slimfast TOPS Other: Have you tried various calorie and/or fat reduction diets, fad diets, or diets which required the purchase of books or tapes? Yes No If yes, please list: _ Have you been on a medically supervised weight loss program? Yes No If yes, please list the physician/nutritionist, date and results: Have you taken weight loss medications such as Phen-Fen or Redux? Yes No If yes, please list the medication, duration taken, weight loss and reason for stopping? Why are you pursuing surgical attempt weight loss? What are your goals/expectations following surgery? Medications (please specify medication name, dosage and frequency of usage): None
3 Allergies: Yes None Medical, Obesity and Co-morbidity History Please answer these questions to the best of your ability. If a section does not apply to you, please check N/A and go to the next section. Morbid Obesity Suffered from Condition for How Long: Severity: Mild Moderate Severe Risk Factors: None Weight gain of 2 pounds or more per year Family history of obesity High Fat Diet Sedentary Lifestyle Associated Conditions: None Cushing s Disease Diabetes Mellitus Harassment by Peers Hyperlipidemia (high cholesterol) Hypertension (high blood pressure) Hypothyroidism Aggravated By: None High Fat Diet Lack of Exercise Medications Poor Mobility Pregnancy Recent Marriage Recent Surgery Recent Trauma/Injury Smoking Cessation Snacking Diabetes If you do not have diabetes, please check N/A and go to the next section N/A Year of Onset: _ Risk Factors: Ethnicity Diabetes During Pregnancy Age _ Family History Diabetes Mellitus Sedentary Lifestyle Obesity Condition Managed By: Comorbidity: Diet Renal Insufficiency Oral Medications Coronary Artery Disease Insulin Hypertension Hyperlipidemia Hypertension If you do not have hypertension, please check N/A and go to the next section N/A Year of Onset: _ Duration: Severity: Mild Moderate Severe Risk Factors/Context: 3
4 Depression Family history of Hypertension Heavy Alcohol Consumption High Salt Intake Inactive Lifestyle Obesity Oral Contraceptive Usage Sleep Apnea Smoking Steroid Use Comorbidities: Chronic Kidney Disease Coronary Artery Disease Diabetes Mellitus Cardiac Failure Post Myocardial Infarction (heart attack) Stroke Hypercholesterolemia If you do not have hypercholesterolemia, please check N/A and go to the next section N/A Year of Onset: Status: Controlled Diet Medication Uncontrolled Sleep Apnea If you do not have sleep apnea, please check N/A and go to the next section N/A Year of Onset: Severity: Mild Moderate Severe Status: Improving Unchanged Worsening Resolved Relevant History: Aggravated By: Weight Change Alcohol Use Time to Fall Asleep Heartburn Awakenings Per Night Sleeping Supine CPAP Use Nasal Problems Daytime Naps Weight Gain Orthopedic History If you do not have significant orthopedic history, please check N/A and go to the next section N/A Do you have arthritis? Do you have joint pain? Quality: (Please circle all that apply) If yes, please specify type: If yes, please specify location: Stiff Tender Sharp Dull Ache Burning Swelling Tingling Hot Sensation Cold Sensation Throbbing Aggravated By: Bending WalkingRunning Pushing Pulling Sitting Standing Lying Down WalkingOveruse Weather Cardiovascular Symptoms If you do not have a significant cardiovascular history, please check N/A and go to the next section N/A
5 Chest Pain (Cardiac) Syncope (episodic dizziness) Dyspnea (shortness of breath on exertion) Edema (swelling feet/legs) Nocturia (urination at night) Irregular Heartbeat/Palpitations Gastrointestinal Symptoms/Disease If you do not have a significant history of gastrointestinal symptoms or disease, please check N/A and go to the next section N/A Abdominal Pain Heartburn Bloating Dysphagia Constipation Nausea Diarrhea Reflux Vomiting Gynecologic History/Symptoms If this section is not applicable, please check N/A and go to the next section N/A Infertility Urinary Tract Infections Fibroids/Tumor in Uterus Ovarian Cyst Menstrual (Painful/Heavy) Postmenopausal Pregnancy History: Total Number of Pregnancies: Total Number of C-sections: Total Number of Living Children: Total Number of Natural Births: Metabolic/Endocrine Disease If you do not have a significant history of metabolic/endocrine symptoms or disease, please check N/A and go to the next section N/A Abnormal Hair Distribution Hypoglycemia Abnormal Sleep Pattern Infertility Cold Intolerance Numbness Decreased Activity Polydypsia (frequent urination) Excessive Diaphoresis (sweating) Polyphagia Generalized Weakness Polyuria Goiter Tremors Hair Loss Weight Gain Heat Intolerance Psychologic History Please answer all questions in their entirety Are you currently depressed? If yes, are you being treated for this? Name of provider and medication given, if any: Have you ever felt depressed for two or more weeks at a time? Are you currently taking any other prescribed psychiatric medications? 5
6 Have you had psychological or psychiatric counseling for weight loss or problems associated with loss? If yes, please describe: Do you feel discriminated against at work? Have you ever experienced any suicidal ideation or episodes? Have you ever been hospitalized for psychiatric reasons? If yes, why, when and for how long? Have you ever been addicted to drugs or alcohol? If yes, please specify: _ Do you, or have you ever: Forced yourself to vomit? Gone for an extended period of time without eating? Had episodes of binge eating? Exercised excessively? Had excessive use of laxatives? Is your life more stable than it was a year ago? Do you overeat in reaction to feelings? (anger, anxiety, stress) Is your family supportive? Is your spouse supportive? N/A Past Medical History: (Please indicate if you had/are being treated for any of the following) Alcoholism Cancer (Type )* Gallbladder Disease PUD Allergies Cardiac Arrest GERD Psychosis Anemia Cardiac Arrhythmia Hepatitis Seizures Angina Cardiac Vascular Disease HIV/AIDS Sleep Apnea Anxiety CVA (stroke) Hyperlipidemia Thyroid Arthritis COPD Hypertension Asthma Coronary Artery Disease IBD Atrial Fib Crohn s Disease Liver Disease BPH Dementia Migraine Bleeding Depression MI Blood Clots Diabetes Osteoarthritis Blood trans DVT Osteoporosis *Details (Please specify type of cancer, treatment and whether you are in remission): Past Surgical History: (Please indicate if you have had any of the following)
7 Appendectomy Gastric Band/Bypass/Sleeve Back Surgery Hernia Repair Breast Surgery Laparoscopy Cholecystectomy (gall bladder) Other: Cosmetic Tonsillectomy Family History: Please check if you have a family history of any of the following medical conditions. Please specify for the family member Disease Mother Father Brother/Sister Grandmother Grandfather Obesity Hypertension Heart Disease Stroke Diabetes Total Number of Siblings: _ If the following family members are deceased, please specify the cause of death and age at death, if known: Mother: Cause & Age: Father: Cause & Age: _ Brother(s)/Sister(s): Cause & Age: _ Grandparents: Cause & Age: (Maternal) Grandparents: Cause & Age: (Paternal) Social History: Marital Status: Single Married Separated Divorced Widow(er) Number of Children: Tobacco Use: Have you ever smoked cigarettes? Used other tobacco products? If yes, how many packs/day? How long? If you stopped, please indicate when you quit: Method Used in smoking cessation or attempts: Alcohol Use: 7
8 Do you drink alcohol? If yes, what type? Frequency: _ Amount: Last Drink: Lifestyle: Activity Level (do you exercise?): Health Club Member Type of exercise/activity: Exercise Frequency (hours per week): I have filled this form out to the best of my knowledge and will provide details or medical records from other providers if requested for my treatment plan and course with this practice. Patient Signature: Date: Review of Systems and Physical Exam: (to be filled out by the consulting physician) Review of Systems: Head Heart GI Skin Neck Lungs GU Musculoskeletal Physical Exam: Weight: Height: BMI: Pulse: BP: Pulse Ox: Temp: HEENT: Neck & Thyroid: Chest: Lungs: Heart: Abdomen: Extremities:
9 Eating History: Eating Habits: graze eater binge eater night eater stress eater Types of Food: carbohydrates sweets salty fast food Portion Size/Frequency of Meals: Impression & Plan: Refer to Checklist for Workup Plan and appointments to be completed Special Instructions given to Patient Patient needs to follow up in the office in: Patient needs to quit smoking Patient needs to complete the following and then return to office after testing below: Provider Signature: _ Date: 9
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Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
HD CLINIC MEDICAL HISTORY FORM
HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Last Name: Date Of Birth: Contact Preference Email Telephone call- Work Telephone call - Home Email Please check one as your preferred
Health History Intake Form;
Health History Intake Form; Today s Date: Patient Name: Date of Birth: Age: Previous Primary Care Physician (if any): Phone: Address: Other Physicians involved in your care: Reason for visit today: Allergies
Welcome to our Center! We are so glad you have chosen our center to assist you with your weight loss goals!
Welcome to our Center! We are so glad you have chosen our center to assist you with your weight loss goals! What to expect.. Your first appointment with our center will last approximately one hour, possibly
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP
Bariatric Surgery. Website: http//baybariatricsurgery.com
Bay Bariatric Surgery Kevin L. Huguet, M.D. General Surgery Laparoscopic Surgery Bariatric Surgery George Rossidis, M.D. General Surgery Minimally Invasive Surgery Bariatric Surgery Website: http//baybariatricsurgery.com
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely Date: email address: First name: Middle: Last: Nickname: Ethnicity/Race (please circle): Black or African American Caucasian Hispanic
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
HEALTH TRANSITIONS CLINC: PART 1: Weight, Diet and Exercise History
HEALTH TRANSITIONS CLINC: Initial history questionnaire: Patient Name: DOB: Age: Sex Marital Status Occupation: Significant Other s Name PART 1: Weight, Diet and Exercise History Obesity history: Current
Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
Questionnaire. General Questions: DOB: Current address: Daytime phone #: Evening phone #: Current occupation:
Submit your completed questionnaire to the Women s Center Coordinator Fax: 713.798.2689 or Mail: Women s Center for Comprehensive Care Baylor Clinic 6620 Main Street, Ste. 1225 Houston, TX 77030 Questions?
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Evolve180 / Ideal Northwest Health Profile
Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital
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