PeaceHealth Southwest Weight Loss Surgery Process

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1 PHSW Weight Loss Surgery Center PHSW Specialty Clinic 8716 E Mill Plain Blvd. Vancouver, WA Phone (360) Fax (360) PeaceHealth Southwest Weight Loss Surgery Process What is the next step? 1. Please complete the patient questionnaire; incomplete information will cause a delay in the weight loss surgery verification process. 2. Mail/Fax/ the completed patient questionnaire with a copy of your insurance cards, both front and back, to the PHSW Weight Loss Surgery Center. 3. Once received, the patient questionnaire will be reviewed to determine patient eligibility for the Weight Loss Surgery Program. 4. Insurance benefits will be verified to determine if the insurance plan provides coverage for Weight Loss Surgery. 5. The PHSW Weight Loss Surgery Coordinator will contact you to schedule your pre-surgical workup. Please call the PHSW Weight Loss Surgery office with any questions you may have regarding the above listed processes. Thank you. Weight Loss Surgery Patient Coordinator Phone: Fax:

2 Weight Loss Surgery Department P. O. Box 1600 Vancouver, WA (360) FAX (360) Patient Questionnaire Information Session Attendance Date: / / Surgery of Interest: Gastric Bypass Gastric Sleeve Gastric Banding Revision Surgeon Preference: Paul Dally, MD Mark Eichler, MD First Available Contact Preference: Home Work Cell Please Print Patient Full Legal Name: Telephone: Cell: Address: City: State: Zip Code: Social Security Number: Address: DOB: Age: Employer: Occupation: Employer Address: Work Phone: Sex: Male Female Marital Status: Single Married Partnered Divorced Widowed Race: Emergency Contact: Last/First/Middle Telephone: Insured or Subscriber Name (primary): DOB: Insured or Subscriber Name (secondary): DOB: Employer: SSN: Employer: SSN: Primary Insurance Name: Secondary Insurance Name: Identification #: Identification #: Group Number: Group Number: Telephone: Telephone: Comments: Page 1 of

3 Personal Physicians: Provider Full Name Office Phone Number Fax Phone Number Primary Care Other Specialist Other Specialist Current Medications: Please list all prescription medications including over the counter medications, vitamins, herbs, and supplements that you are taking Drug Name Dosage Frequency Number of years taking this drug Allergies: Please list any medication allergies you have. Medication Reaction Medication Reaction Operations: Please list all surgeries that you have had. Surgery Year Please describe if you have experienced any problems with anesthesia during surgery. Procedures: Please check if you have had any of the following procedures and when. Procedure Date Procedure Date Colonoscopy EGD/Upper GI Recent Chest X-ray Page 2 of 5 Echocardiogram Cardiac Catherization Pacemaker

4 Medical History: Please check to any of your following medical conditions and explain as needed below. Heart condition(s): Heart Attack Angina or Chest pain Congestive Heart Failure (CHF) Irregular Heart Beat Pacemaker High Blood Pressure Diabetes: Type 1 Type 2 Sleep Apnea If, do you use a CPAP/BiPAP machine Stroke Peripheral Vascular Disease High Cholesterol High Triglycerides Cancer (If, what type?) Edema or water retention Asthma COPD or Emphysema Pulmonary Embolism (PE-clot in lung) Deep Venous Thrombosis (DVT-clot in leg) Bleeding problems GERD/Reflux Stomach Ulcers Colon or Intestinal problems Swallowing problems Hernia (If, what type?) Gallbladder problems Liver problems Kidney problems Gout Arthritis Degenerative Joint Disease Joint Replacement Fibromyalgia Back Pain Thyroid problems Polycystic Ovarian Syndrome (PCOS) Irregular Menstrual Periods Urinary problems Headaches such as Migraines Psychiatric condition (Bipolar disorder, eating disorder, etc.) Depression Page 3 of 5 (If, please include the year of onset below.)

5 Family History: Which members of your family are or were morbidly obese ( 100 lbs overweight)? Father Mother Brother(s) (how many?) Sister(s) (how many?) Is your father alive? Age at time of death? Cause of Death: Does he have/had? Diabetes Heart Disease High Cholesterol Is your mother alive? Age at time of death? Cause of Death: Does she have/had? Diabetes Heart Disease High Cholesterol How many obese family members (include grandparents, aunts, uncles,etc. )? Total #: Social History: Work Information: Full Time Part Time Self-employed Homemaker Student Retired Disabled Unemployed Occupation: Marital Status: Single Married Partnered Divorced Widowed # of children and ages? Social Habits: Do you drink alcohol? If, how often? Do you currently smoke or chew tobacco tobacco? Have you ever smoked or chewed tobacco tobacco? When did you quit? Do you use recreational drugs? Review of Symptoms: Please check to any of your following symptoms and explain as needed below. Fatigue Insomnia Rashes or Skin problems Headaches Dizziness Vision or Hearing problems Hoarseness Difficulty chewing Difficulty swallowing Heartburn or Acid Reflux Nausea or Vomiting Abdominal pain Cough or Shortness of Breath Chest pain or Palpitations Back pain or Joint pain Swelling in legs Irregular Menstrual Periods Difficulty urinating, frequent urinary tract infections, or leakage of urine Depression Page 4 of 5

6 Weight History Height: Current Weight: Weight Date For how long? Since age 18, the least you have weighed? The most you have ever weighed? How much weight do you expect to lose after surgery? How often do you weigh yourself? Have you ever had any of the following surgical procedures for weight loss? Surgery YES NO Year Gastric Stapling Gastric Bypass Gastric Band Intragastric Balloon Jaw Wiring Diet Program ft. lbs. Start Date in. End Date If you marked YES to any of these surgical procedures, was it later reversed? Duration NO YES Date: Diet History: Please list the diets and/or medications that you have tried, time on these diets, and the amount of weight lost. Start Weight End Weight Weight Change Examples Diets: Weight Watchers, Jenny Craig, Nutrisystem, LA Weight Loss, HMR, MD Supervised, Optifast/Medifast, Atkins, South Beach, Calorie counting, Diabetic diet, Portion control, Cambridge, Mayo Clinic, Zone, Dean Ornish, Pritikin, DASH, Increased exercise, American Heart Association, Slim-Fast, Prism, Sugar Busters, TOPS, Overeaters Anonymous, Grapefruit, Cabbage Soup, Metabolife, Suzanne Sommers, Blood Type Diet Pills/Medications: Phen/Fen, Meridia, Phentermine, Xenical, Alli, Metabolife, Trimspa, Dexatrim Physical Activity: Are you able to exercise? YES NO If YES, how often? What type of exercise do you do? If you answered NO, please describe the reasons why not. Page 5 of 5

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