Medical History. Past Medical History
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- Terence Melton
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1 Regional Surgical Associates Dr. Adam S. Goldstein Medical History Date Name Social Security Number - - DOB Age Height Weight BMI Primary care doctor For office use only Height Weight BMI Neck Goal Ideal BMI>45 Age>38 Apnea HbA1c Insulin Male Past Medical History Please circle the appropriate response Bleeding Blood clots in the legs Rheumatic fever Blood clots to the lungs Thyroid problems Diabetes currently Tuberculosis Diabetes while pregnant Urinary tract infections Age at onset of diabetes Kidney disease Diabetes control good poor Hepatitis Polycystic ovarian Do you have to take syndrome (PCOS) antibiotics before Problems with anesthesia dental work Hypertension (high blood AIDS/HIV pressure) High cholesterol or triglycerides Past Surgical History Please list all surgeries and approximate dates (year) Past Hospitalizations Please list all hospitalizations and approximate dates (year)
2 2 Review of Symptoms General Infection Fevers HIV Sweats AIDS contact Fatigue TB exposure Loss of appetite Swollen glands Bloody sputum Recurring infections Persistent cough Skin infections Skin Exercise Limitations Rash Mild Skin cancer Moderate Senses Severe Visual problems Pain in joints Hearing problems Back Ear ringing Hips Neurological Knees Dizziness Feet Migraines Arthritis Seizures Where Strokes Gastrointestinal Memory loss Heartburn/acid reflux Shaking Stomach pains Numbness Stomach ulcers Uncoordination Gastritis Genito-urinary H. pylori infection Blood in urine Rectal bleeding Vaginal infections Liver disease Stress urinary incontinence Hepatitis or cirrhosis Bladder/kidney infections Colitis or enteritis Prostate infections Stomach surgery Sleep apnea Physical limitations Snoring Climbing stairs Require C-pap Unusual fatigue Daytime drowsiness Airline travel Frequent waking at night Lifting from floor Choking at night Use of public seating # of pillows used Personal care Pulmonary disease Tying shoelaces Short of breath on exertion Playing with children Hay fever Gynecological Emphysema/COPD Last menstrual period Asthma Pregnancies Aspiration/choking Current contraception Any chance you are currently pregnant
3 3 Review of Symptoms (continued) Cardiovascular Psychological Heart attack Depression Congestive heart failure Feeling down Thrombophlebitis Suicidal episodes Swelling of ankles Mood swings for days Chest pain at a time Coronary heart disease Hospitalized for Varicose veins psychiatric reasons Heart murmur Use alcohol or drugs to Pulmonary embolism cope Stroke Eating disorder Ever taken Fen-Phen Vomiting to lose weight Fasting to lose weight Laxatives to lose weight Life more stable than a year ago History of sexual abuse Psychiatric medications in past or present Overeat in reaction to feelings Is your spouse or significant other supportive of weight loss surgery Age you first became overweight Epworth Sleepiness Scale Note: the Epworth Sleepiness scale refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. Scale Situation Likelihood 0 = would never doze Sitting and reading 1 = slight chance of Watching TV dozing Sitting, inactive in a public place 2 = moderate chance of As a passenger in a car for 1 hour, no dozing break 3 = high chance of dozing Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, stopped in traffic
4 4 Medications List all daily medications including over-the-counter medications and vitamins, herbs or supplements Aspirin NSAIDS Ibuprofen Insulin Aleve Steroids yes No Medication allergies Allergies Please list any known allergies or sensitivities allergies Sensitive or allergic to Latex Iodine Dye Tape
5 5 Social History Marital status _ Single _ Married/Partnered _ Divorced/Separated _ Widowed Religious preference Education Number of people living in your home What type of work do you do Do you smoke Do you drink alcohol How many per day How many per day How much and how often How much and how often Do you use controlled substances How does your spouse or partner feel about weight loss surgery Family History Disease Who in your family had it When Was it fatal Cancer (what type) Diabetes Heart attack Severe obesity
6 Body For Life/Bill Phillips Gloria Marshall Health spa High protein Hypnosis Low carbohydrate Low fat Calorie counting on my own Gym membership Home gym equipment Diet Pills From MD Diet Shots From MD Diet Center Overeaters Anonymous Optifast Weight Watchers Health Management Resources (HMR) Nutri-System T.O.P.S. Jenny Craig New Direction National Weight Loss Acutrim Adipex-P Amphetamines Anorex Benzphetamine Dexatrim Didrex Fastin Fenfluramine Herbal Remedies Ionamin Mazanor Meridia Metabolife Gastric bypass (RNY or other) Stomach stapling Vertical banded gastroplasty 6 Weight Loss History Please check all that apply. Non-Supervised Attempts Atkins Diet AYDS Mayo Clinic Diet Pritikin Richard Simmons Scarsdale Diet Stillman Diet Sugar Busters Slim Fast South Beach Diet Supervised Weight Loss Attempts Weight Loss Medications Supervised Calorie Counting Acupuncture Psychological Counseling Weigh Of Life Weight Loss Center Exercise Counseling Medifast Metrical Nutritional counseling Personal Trainer Obalan Orlistat Phendiet Phentermine Phentrol Plegine Pondimin Redux Sanorex Tepanol Tenuate Wehless Xenical Previous Weight Loss Surgery Gastric band
7 7 Nutrition History How many meals do you eat daily Do you snack between meals Do you drink soda Diet Regular How many sodas do you drink daily Food Preferences Candy Fast food Cookies Seafood Fried food Cakes or pies Pizza Vegetables Chocolate Steak or red meat Chips and snacks Dairy products yes No Food allergies Before breakfast Food Patterns Please record the type of food and the amount you have eaten over the past two days. All foods eaten the day All foods eaten yesterday before yesterday Breakfast Morning break Lunch Afternoon snack Dinner After dinner Before bed
8 8 Patient Experience Questionnaire How did you hear about the Lap-Band? How did you hear about Dr. Goldstein? Why have you chosen the Lap-Band procedure rather than other weight loss surgery? When and where did you attend the information session? Did the information session influence your decision regarding the Lap-Band? If so, how? Is there anything about the information session that you would change? How would you improve your experience thus far with either Dr. Goldstein's practice or the New Beginnings program? Do you use the internet to research topics that you are interested in? If so, what sites do you use? Do you subscribe to any of the following: SJ Magazine, South Jersey Magazine, Philadelphia Magazine, or other magazines? What newspaper(s) do you subscribe to? Do you read the "Sun" newspapers (Cherry Hill, etc.)? What is/are your favorite radio station(s)?
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Pre-Test Questionnaire Date: Hospital # (Please Print) Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over Chief Complaints What problem(s) brings you to sleep disorders
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Integrative Consult Patient Background Form
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McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
130 Preston Executive Drive Cary, NC 27513 Ph(919)462-8081 Fax(919)462-8082 www.parkwaysleep.com Page 1 of 6 Patient History *Please fill out in dark BLACK INK only. General Information Name Sex: Male