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1 1. Thank you for choosing University Bariatrics. Please take your time and fill out this application in full. You may forward the completed questionnaire to us via mail, fax, or University Bariatrics 42 Haaland Drive. #203 Thousand, Oaks, CA Fax : (80) coordinator@universitybariatrics.com If you have any questions, please do not hesitate to contact us at (80) or via . We look forward to seeing you soon. For the University Bariatrics Team Amir Mehran, MD 1. Your full name 2. Your date of birth? 3. Mailing address: 4. Best telephone number(s) to reach you and leave private messages.. address(es) where you can receive personal private s.. Emergency contact information: Page 1
2 7. Primary care MD: Please include full name, address, phone and fax, and if known, address 8. Please provide the name, specialty, and complete contact information for your other doctors & healthcare providers 9. How long have you been contemplating bariatric surgery? less than months 12 months more than 1 year 10. How have you researched about bariatric surgery? Internet Magazine articles Bariatric surgery support meetings Weight loss surgery seminars TV programs Discussed with PCP/ MDs Books Talked to people who had surgery 11. A pre consultation information seminar attendance is highly encouraged and sometimes mandatory in bariatric surgery. Please indicate which one of the following applies to you? I have attended a University Bariatrics seminar online I have attended online seminars by other practices I have attended a University Bariatrics seminar in person I have attended in person seminars by other practices I have attended a LaPeer seminar online I have not attended any bariatric surgery seminars I have attended a LaPeer seminar in person Page 2
3 12. How did you hear about University Bariatrics? PCP referral Other internet search enginesa such as Bing, Yahoo, etc Other physician or healthcare provider LaPeer (website or banner ads) Friend or family member or coworkers Social internet sites such as Facebook, Twitter etc Advertisement in print media Obesityhelp.com website Google Other Other (please specify) 13. At what age did you first start dieting? 14. Which of the following diets have you been on in the past. Please mark all that apply. Jenny Craig Nutrisystems Overeaters Anonymous or similar Atkins or Zone Slimfast Hypnosis Dr. Phil/Dr. Ornish/similar programs Optifast Jaw Wiring South Beach Diet Thyroid medications Weight loss boot camps or 'farms' Trim Spa 'Speed' or similar drugs Personal trainer program Weight Watchers Diet pills or shots (over the counter, TV Dietician supervised program Lindora Phen Fen or its later derivatives Optifast promotions, 'diet clinics') Xenical Meridia Alli If other: please specify each diet/weight loss program on a separate line Page 3
4 1. IN THE PAST TWO YEARS SPECIFICALLY, which one of the following MD or nutritionist SUPERVISED programs have you been on, for how long, and how much weight did you lose? for less than 3 months for 4 months more than months I lost less than 10 pounds I lost more than 20 I lost pounds pounds Jenny Craig Weight Watchers Lindora Optifast Nutrisystems Personal trainer supervised weight loss program Dietician supervised weight loss program 1. What was the most successful weight loss program ever and how much weight did you lose. Please indicate approximate year or age. 17. Are you a sweet eater? If so, please indicate type, amount, and freqency on a weekly basis Yes No If yes: Please specify 18. Are you a carb eater? If so, please indicate type, amount, and freqency on a weekly basis Yes No If so, please specify Page 4
5 19. Are you a fast food eater? If so, please indicate type, amount, and freqency on a weekly basis Yes No If yes, please specify: 20. On a typical day, how much soda or other non alcoholic beverages do you consume daily? None 8 oz or less(one can) 1 24 oz (2 3 cans) 3 4 oz More than 4oz Soda Diet Soda Juice Crystal Lite or similar artificially sweetened drinks Sports drinks (Gatorade) Energy drinks (RedBull) Coffee Decafeinated coffee Coffee drinks (eg latte, capuccino, machiatto, frappucino, etc) 21. Which one of the following applies to you: I snack all day from habit or boredom I don't think that I eat much but make incorrect choices I rarely snack between meals I binge eat (eg at buffets, night time 'raids' on the fridge) I don't snack at all I eat in response to stress, anxiety, anger, or depression I practically don't eat all day & have a large dinner at night I starve myself in response to above I eat the typical three meals only I am always hungry and constantly eating Other (please specify) 22. Please indicate your height, weight, and BMI (if known) Page
6 23. Cardiac history: Please mark all that apply. High blood pressure (including medication controlled) Pulmonary hypertension Heart attack Known abnormal EKGs Congestive heart failure Swelling of the legs during the day Abnormal heart rhythms I have or have had a pacemaker Other Murmurs 24. Pulmonary History: Please mark all that apply. Known obstructive sleep apnea on CPAP or BiPap Asthma Known obstructive sleep apnea but not on CPAP or BiPap Shortness of breath on exertion eg going up stairs Tuberculosis or fungal infections Lung or other airway cancer History of pneumonia Emphysema Page
7 Please calculate your sleep score and document below. Score above 9 may indicate sleep apnea. 2. Gastrointestinal history: Please mark all that apply. Heartburn (gastric reflux disease) Lactose intolerance Documented gastroparesis Inflammatory bowel disease (ulcerative colitis or Crohns) Barretts esophagitis Rectal bleeding Pernicious anemia Colon or small intestine polyps Gastric polyps Fatty liver Biliary colic (gallbladder pains) Liver cirrhosis Diarrhea Any gastrointestinal cancer Constipation Irritable bowel syndrome Celiac sprue Page 7
8 2. Endocrine history: Please mark all that apply. Insulin treated diabetes Hypothyroidism (underactive) Oral medication treated diabetes Endocrine cancers such as thyroid, adrenal, pituitary, etc Hyperlipidemia (cholestrol and/other lipids) Hyperthyroidism (overactive) 27. Hematological history: Please mark all that apply Religious or cultural opposition to blood transfusion even if it means saving one's life Abnormal bleeding (ie do not clot easily) Hemophilia Known clotting disorders (ie hypercoagulable diseases) History of pulmonary embolus IVC filter Any form of immunodeficiecy such as HIV Hepatitis A or B or C Leukemia Lymphoma History of blood transfusion 28. Urinary history: Please mark all that apply Stress urinary incontinence Kidney failure history (now or in past) "Suspension surgery" for stress incontinence Dialysis dependent Benign prostatic hypertrophy Urological cancers Any prostate surgery Frequent urinary tract infections Page 8
9 29. GYN history (women only): Please mark all that apply Menopause Hysterectomy Irregular periods/vaginal bleeding not related to menopause GYN hormones (eg birth control pills, depo shots) Endometriosis Any GYN cancer Polycystic ovarian disease Infertility Tubal ligation Other (please specify) 30. Musculoskeletal history: Please mark all that apply Joint pains in neck & shoulders related to being overweight History of orthopedic surgeries Back pain related to being overweight Hip, knee or foot pains related to being overweight Diagnosed with early arthritis Severe arthritis or joint loss requiring orthopedic surgery I have been told that my weight prevents me from having necessary orthopedic surgery 31. Neurological history: Please mark all that apply Stroke Tumors Migraines or other severe headaches Pseudotumor cerebri Other (please specify) Page 9
10 32. Psychological history: Please mark all that apply. Depression Anorexia/bulemia Muliple personality disorder Anxiety History of suicide Schizophrenia or similar diagnosis Panic attacks Obsessive compulsive disease (eg wash Chronic fatigue syndrome hands several times) Bipolar disorder 33. Other history: Skin cancers or precancerous lesions Eye problems Hair loss HIV or other immunodeficiency Psoriasis or Eczema Other (please specify) 34. Have you had previous weight loss surgery such as gastric bypass, adjustable bands, gastroplasty etc? I have not had weight loss surgery in the past I have had weight loss surgery in the past. I have had weight loss surgery in the past as well as one or more revisions. 3. If you have had previous weight loss surgery, please indicate which one(s). Gastric bypass Vertical Banded Gastroplasty (VBG aka stomach 'stapling') Adjustable or nonadjustable bands Biliopancreatic Diversion (with or without Duodenal Switch) I have had previous weight loss surgery but is not listed above I don't know what weight loss procedure I had done in the past. Page 10
11 3. Other past medical or surgical history or hospitalizations not mentioned above. Please include approximate dates and write on SEPARATE lines for each event. 37. If you have had general anesthesia before, i.e. have been put to complete sleep for a surgical procedure, please check the appropriate box. I have never had general anesthesia I have had general anesthesia in the past and had no problems I have had general anesthesia in the past and had problems If had problems, please elaborate: 38. COMPLETE list of prescription medications, preferably with dose and frequency. 39. COMPLETE list of non prescription, over the counter, or herbal medications and supplements. 40. Drug or other chemical allergies No drug, chemical, or food allergies Latex allergy Allergies to other medications or Food allergies IV dye allergy (eg for CT scans or other chemicals xray tests) Please specify EACH allergy on a SEPARATE line and include what kind of reaction (eg nausea, rash, stop breathing, etc)) Page 11
12 41. Family history: Please mark all that apply. Obesity Heart disease Neurological disorders such as Cancer Blood clots and embolism Diabetes High blood pressure Hyperlipidemia Strokes Parkinsons, Alzheimers, etc Anesthesia problems Other (please specify) 42. Current alcohol history: none Less than five drinks per week More than drinks per week Beer Wine Other liquor 43. Current tobacco/nicotine history: None Less than pack/roll/box a day More than one pack/roll/box a day Cigarettes Cigar Chewable tobacco If past user and have quit: please indicate when 44. I currently use drugs including medical marijuana. If yes, please elaborate type and amount. Yes No If yes, please specify type and amount 4. What is your current occupation 4. Marital status Married with kids(including life Married without kids Single partnership) Age of kids? Page 12
13 47. With whom do you reside? Mark all that apply I live by myself Roommate Spouse or partner Others including elder relatives and friends Children 48. What is your highest education level? Middle school College (2 or 4 year) Prefer not to answer High school diploma or equivalent Graduate school Technical/vocational school 49. Having a support system before and after surgery is vital to successful and safe outcomes. Spouse Other family Overeaters Anonymous or similar Children Friends None Siblings Church or similar Other If other, please specify 0. What are your primary goals and reasons to pursue weight loss surgery? 1. This application has been filled out by myself or with the help of someone else under my guidance. In either case, by signing and dating below, I attest that all the information is accurate to the best of my abilities. Page 13
7. What is your insurance? Please include as much information as possible including policy number.
1. Thank you for considering our practice. Once you hit DONE at the end of the questionnaire, your application will be submitted to us electronically and in a HIPAA compliant fashion. If you have not heard
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McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
Name: Today s Date: Address: State, Zip Code
New Patient Health History Questionnaire Name: Today s Date: Address: City State, Zip Code Email Address: Date of Birth: Home Telephone #: Cell Number: Work Number: Emergency Contact name & number: Referred
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Visit My Doctor Online at kp.org/mydoctor. Prepare for your visit This form will help you prepare for your upcoming visit with your doctor. You can complete it on your computer (Mac or PC) and e-mail it
BARIATRIC SERVICES HEALTH HISTORY PROFILE
LAP-BAND GASTRIC BYPASS GASTRIC SLEEVE OTHER FIRST NAME: INITIAL: LAST NAME: DATE OF BIRTH: REFERRING DOCTOR: CELL#: E-MAIL: REASON FOR VISIT: EMERGENCY CONTACT PERSONS: NAME/RELATION: PHONE#: ADDRESS:
Health History. Date. Address. City State Zip. Age Height Weight BMI. Date of birth Male Female. . Are you currently a patient at OHSU?
OHSU BARIATRIC SERVICES Health History Please fill out this form completely and email or fax to the contact information at the bottom of this form. We will contact you to set up an appointment. Date Name
Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
NEW PATIENT HEALTH ANALYSIS
NEW PATIENT HEALTH ANALYSIS Name: DOB: Date: Which program are you interested in? Unsure Medical Weight Management (Non-surgical) Bariatric Surgery (See options below) Roux-En-Y Gastric Bypass Sleeve Gastrectomy
Do you exercise? Yes No If yes, what kind? How often?
HEALTH PROFILE Dietary consultation involves a health profile which purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight-loss plan.
Mercy Metabolic and Bariatric Surgery Program Questionnaire
Mercy Metabolic and Bariatric Surgery Program Questionnaire Interested in bariatric surgery? Complete this form and return to us to be considered for evaluation: Sara Maduka, Mercy Metabolic and Bariatric
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Centra Weight Loss Clinic Initial Appointment Questionnaire
*Please note: To provide appropriate care, forms MUST be completed prior to your initial visit. Name Date of Birth Physician Information Referring Physician / PCP (Name) Location (city, state) Date of
Initial Client Questionnaire
Initial Client Questionnaire First Name: Middle Initial: Last Name: How did you hear about my services: Medical History Pregnant: Yes No Nursing: Yes No When was your last physical exam? What are your
PATIENT INFORMATION (Please print all information) Date:
320 Lillington Ave Suite 101 Charlotte, NC 28204-3189 Phone: 704.362.4403 Fax: 704.362.4405 Please fill out the following form completely so that we may obtain the necessary information for our files and
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
Comprehensive Patient History Form
Comprehensive Patient History Form Date: Name: D.O.B. Past Medical History: (check all that apply) Acid Reflux Cataracts Heart disease Migraines Alcohol or Drug Problem Colitis/Crohns Heart valve problems
PLEASE COMPLETE ALL SECTIONS OF THIS FORM
PLEASE COMPLETE ALL SECTIONS OF THIS FORM Patient Name: Date of Birth: Referring Doctor? (Name, telephone number and address) Chief Complaint: Why have you come here? How did it start? What are the symptoms?
OhioHealth Orthopedic & Sports Medicine Physicians
Page 1 of 6 OhioHealth Orthopedic & Sports Medicine Physicians 335 Glessner Avenue, Mansfield, Ohio 44903 PATIENT INTAKE ASSESSMENT OFFICE USE ONLY Fax to: OR Control 419-520-2831 For Joint Replacement
Please answer all questions to the best of your ability. Patient name: Date: SS#: Age: Address: Date of Birth: City/State/Zip Code: Sex: MALE FEMALE
Please answer all questions to the best of your ability. Patient name: Date: SS#:_Age: Address: Date of Birth: City/State/Zip Code: Sex: MALEFEMALE Phone (home): (work):(cell): Marital Status: e-mail address:how
New Patient Medical History Form
New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring