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1 Office use only: MRN BMI Please complete and return this form to be considered for evaluation Name Date Age Date of Birth / / Sex M F Address City State Zip code Preferred Daytime Phone: ( ) - Do you have that is checked regularly? Can we use it as a way to contact you with appointment information? No If, please provide it Type of weight loss services interested in: Preferred surgeon: Have you previously had bariatric surgery? NO YES* When: _ Where: Type: _ Reason(s) for seeking a revision: *please provide original bariatric surgery op report and recent testing with this questionnaire Primary Insurance: ID# Group# Policy holder Relationship Customer Service Phone# Secondary Insurance: ID# Group# Policy holder Relationship Customer Service Phone# Self-Referred Medically Supervised Weight Loss Surgical Weight Loss Undecided Both Dr. Wheeler Dr. Ganga Dr. Pitt Dr. Spencer No Preference Physician Referred - Name Phone ( ) - Current Height: feet inches Current Weight NOTE: Education regarding bariatric surgery is done in a group setting format due to the number of people requesting bariatric surgery. Please know that all personal information is kept private during these classes. It will be your decision to share personal information or ask individual questions during the group sessions. 1
2 OBESITY RELATED COMPLAINTS: (please X all that apply) Have you EVER had any of the following: Past / Now Condition High blood pressure Diabetes Sleep Apnea w/ sleep study Daytime Sleepiness Snoring Reflux (heartburn) Heart disease High Cholesterol High Triglycerides Joint pain Back pain Hip pain Knee pain Ankle & foot pain Swelling of feet Urinary stress incontinence Blood clots Deep vein thrombosis DVT Pulmonary embolism PE Stroke Shortness of breath Asthma Emphysema Headaches Migraines Kidney disease Seizures Rashes Arthritis / Osteoarthritis Cancer Irregular periods Eating disorder Non Alcoholic Fatty Liver or Non Alcoholic Steatohepatitis Other (please specify) Additional space - next page Medication/Treatment needed (name and dosage) 2
3 Past / Now Psychiatric History Medications Depression Severe depression Schizophrenia Bipolar Anorexia Bulimia Treated by a mental health provider Hospitalized for mental health Dates hospitalized for mental health History of suicide attempt? When? History of drug abuse treatment? When? Mental Health History explanations: Family History (Check all those that apply) Mother / Father Heart Disease Diabetes Hypertension Condition Cancer Type(s) Stroke Obesity Deep Vein Thrombosis (blood clot in legs) Pulmonary Emboli (blood clot in lungs) Please list any health conditions in your immediate family: Medication History: (Current) Medication (s) Dosage and Reason for Taking 3
4 MEDICAL HISTORY: (list any other conditions not addressed on previous page) SURGICAL HISTORY: SOCIAL AND PERSONAL HISTORY: Highest level of education: Occupation: Employer name: (for our records only) Do you use tobacco/nicotine products? (chew, cigarettes, cigars, e-cig, pipes, etc)? Never Past - When quit? Currently - How Much? Do you have a history of either alcohol, drug/substance abuse? No * *If do you currently use? No. What type did you use? When did you quit?. What type do you use? How often? EXERCISE PROGRAM (What is your exercise program): I am unable to exercise due to - severe joint pain shortness of breath wheelchair/bed I am able to exercise but I do not have a regular routine I currently exercise by doing: Other (please explain) DIETARY HISTORY: 4
5 Do you follow a special diet: Currently? no yes Name/type of diet attempt Date started (month/year) / Beginning weight pounds lost pounds gained Programs/Prescription Drugs/Over the Counter Medications attempted: (mark all that apply) Nutri- System Center High Protein Medifast Gluten Free Cabbage Soup ABS Zone Grapefruit Weight Watchers Paleolithic Blood Type Low Calorie Jenny Craig Perricone Low Sugar Fitness Centers Flat Belly Sugar Busters Over Eaters Anonymous Subway Magazine Mediterranean Vegan/Vegetarian Self-Imposed Fasting Liquid Protein Low Fat Hypnosis Atkins Exercise Videos Body for Life Fit For Life Herbal Belly Off Spark People South Beach Eat This, Not TOPS That Detox Diabetic Juice DASH Raw Food The Cookie Ornish HCG Phentermine Tenuate Amphetamine Qsymia Phen- Fen (Adipex) Wellbutrin Bontil Belviq Xenical Ritalin Didrex Orlistat Topomax Meridia Dexatrim Hoodie Metabolife Zovetal Sensa Cortislin Hydroxycut Nanoslim MuHaung Relecore Leptopril Trim Spa Alli Lipozene Stacker Actislim Green Tea Extract Which meals do you eat each day? Breakfast Lunch Supper Do you snack? no yes How often? mid-morning afternoon evening just before bed What do you typically eat for snacks? Do you drink milk? no yes What kind? Do you drink plain water? no yes How much? Do you drink soda? no yes How often? Do you drink juice? no yes How often? Do you consume alcoholic beverages? No - If yes, how many drinks per week? What other beverages do you drink? (tea sweet-unsweet, carbonated/sparkling water, energy, etc) Do you have food allergies? no yes What? Allergies: Allergic to Latex? No Any known drug allergies? No If yes, list of drugs: 5
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NAME NAME ADDRESS ADDRESS. PHONE PHONE Cell Phone DATE OF BIRTH DATE OF BIRTH OCCUPATION OCCUPATION MARITAL STATUS MARITAL STATUS
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** Page 1 of 11 Date of Visit: PATIENT INFORMATION 1) Child's Last Name First Middle 2) Date of Birth (mm/dd/yy) 3) Your relationship to child: Biological mother Biological father Other (specify) 4) REFERRING
Single - Married - Divorced - Widow - Other Spouse s Employer (if applicable)
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Last Name: First Name: MI: 1. Have you recently had any major family changes: If yes, please explain:
Adult Medical Questionnaire Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
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