Dr. Edmund P. Chute, MD

Transcription

1 Date attended class: Dr. Edmund P. Chute, MD Procedure of choice: Laparoscopic Roux-en-Y gastric bypass Sleeve Gastrectomy Unsure Personal Information: First Name: Middle Initial Last Name Social Security: - - Date of Birth: Gender: Race Marital Status: Spouse s/partner s name: Home Information: Street Address: City: State: Zip Code: Home Phone : - - Cell Phone: - - Work Information: Business Name: Occupation: Street Address: City: State: Zip Code Phone Number: - - ext: Insurance Information: **Please attach photocopy of both sides of insurance card/s** Primary Insurance Company: Subscriber: Street Address City State Zip: Phone Number: - - ID Number: Group Number: Secondary Insurance: Company: Subscriber: Street Address City State Zip: Phone Number: - - ID Number: Group Number:

2 Primary Doctor: First name: Last name: Degree: Specialty: Organization/clinic: Street Address: City: State: Zip Phone #: - - How long have you been going to this doctor? years Fax#: - - Doctor/Specialist First name: Last name: Degree: Specialty: Organization/clinic: Street Address: City: State: Zip Phone #: - - How long have you been going to this doctor? Fax#: - - years Psychologist/Psychiatrist (if you are seeing one) First name: Last name: Degree: Specialty: Organization/clinic: Street Address: City: State: Zip Phone 1: - - Fax #: - - Contact Information: (must list two) EMERGENCY CONTACT #1: Relationship: First name: Last name: Street Address: City: State: Zip Home Phone: - - Cell Phone - - EMERGENCY CONTACT #2: Relationship: First name: Last name: Street Address: City: State: Zip Home Phone: - - Cell Phone: - -

3 Personal Weight History Height: feet in Present Weight: (Office use) BMI Age you 1st became overweight: Age you became 100 lbs overweight: Weight: at age 18 Five years ago: Highest weight in five years Lowest weight in five years Previous dietary weight loss efforts: Name of program or Dr. Start date (M/Y) End Date (M/Y) Starting Weight Ending Weight 1. / / 2. / / 3. / / Health Information: General: How is your health in general? good fair poor Central Nervous System/Psychological: Have you been depressed? Hospitalized for depression? Have you been suicidal? Are you taking medications for depression? Do you have or have you had any other mental health problems? Please describe. Do you have a history of substance or alcohol abuse? Please describe. Average # alcoholic drinks per week: OR per month: Do you have idiopathic intracranial hypertension (high fluid pressure in the brain)? Cardiovascular: Do you have hypertension (high blood pressure)? If so, how many years? Do you have heart disease? If so, please describe. Have you taken phen-fen? When? For how long? # pounds lost on it Pulmonary: Do you have lung problems? Please describe: Do you smoke? Have you quit? When? Do you have asthma? Do you have sleep apnea? Do you use CPAP (continuous positive airway pressure)?

4 Does your family say you have loud and irregular snoring? What is the chance that you would doze off when you are: Sitting and reading? never slight moderate high Watching television? never slight moderate high Sitting inactive in a public place, like in a theater or meeting? never slight moderate high A passenger in a car? never slight moderate high Lying down to rest in the afternoon? never slight moderate high Sitting quietly after lunch (when you have not had alcohol)? never slight moderate high In a car, stopped in traffic? never slight moderate high Office use only: /24 Gastrointestinal: Do you have frequent heartburn? Do you take antacids or other medication for heartburn? Do you have gastroesophageal reflux disease (GERD)? Are you taking medication for GERD? How many years? Have you had an upper endoscopy (gastroscopy)? When? Where was it done? Do you have a history of jaundice or hepatitis? Have you had an ulcer? Genitourinary: Do you have kidney problems? Do you sometimes lose your urine with coughing or sneezing? If so, how often? Have you been diagnosed with urinary stress incontinence? Are you infertile? Have you seen a doctor about this? If yes, what is the diagnosis? For women: # of pregnancies # of babies When was your last period? Musculoskeletal: Do you have bone, joint or muscle problems? Which joints? Spine hips knees ankle other Is there a diagnosis Diagnosis: Do you have lower leg venous stasis ulcers? Do you have fibromyalgia? Hematology/Oncology? Do you have a history of abnormal bleeding or clotting? Do you or have you had anemia (low hemoglobin)? Are you HIV positive? Ever been MRSA+? VRE+

5 Have you had a cancer or any other tumor? When? Where was the cancer? Metabolic: Do you have elevated cholesterol or triglycerides or lipids? Do you have diabetes mellitus ( sugar diabetes )? When diagnosed? Do you take pills for this? Do you take insulin for this? Please list any previous surgery that you have had. Date Family History: Have any of your family members had any of these illnesses? (even if deceased): Relative Weight Diabetes Heart probs or attack Father Mother Brother 1 Brother 2 Brother 3 Brother 4 Sister 1 Sister 2 Sister 3 Sister 4 High blood pressure Sleep apnea High cholesterol Joint problems Stroke or blood clots Medications: Please list all medications, including non-prescription medications and supplements. Medication: Dose: How often do you take it? Purpose of the medication

6 Allergies: Please list any allergy to foods or medications and the reactions that you have to them. Food/Medication When did you have a reaction? What was the reaction? Review of Unrelated Medical Systems: Please check all that you have now or that you have had in the past: excessive fatigue shortness of breath frequent urination wake at night unable to breathe urgency to urinate double vision blood in urine change in vision leg/foot swelling hearing loss heart attack prostate problems fluttering in chest muscle problems frequent ear infections Nose bleeds ear drainage abnormal heart valve frequent cough stroke muscle weakness numbness lumps in nose pins & needles feeling growths in mouth sinus infections excessive urination pneumonia emphysema spinal cord/brain injury blood clot in lungs abnormal bleeding tuberculosis frequent infections blood clot in leg trouble swallowing Lump in neck trouble speaking vomiting constipation diarrhea intolerant of cold lump in breast pancreas problem intolerant of heat gallstones chest pain thyroid problem Crohn s disease blurry vision can t sleep lying down kidney stones ringing in ears leg cramping frequent runny nose muscular dystrophy phlegm production seizures sores in mouth easy bruising frequent nausea stiff neck blood in stool abnormal immune system lump in armpit lump in groin Please tell us anything else that you would like us to know to help us provide you with the best possible care. Authorization to release information: I hereby authorize the physician to release any information acquired in the course of my treatment necessary to process insurance claims. Signature Date Authorization to pay benefits to physician: I understand that as a courtesy to me Ridgeview Bariatric & Weight Loss Center will file insurance claims on my behalf. I understand, however, that I am responsible for payment of services that I have received. I hereby authorize payment directly to the physician of the Surgical or Medical Benefits, if any, otherwise payable to me for his/her services as described, realizing that I am responsible to pay non-covered services. Signature Date Medicare patients: We are participating physicians in the Medicare program and accept assignment of benefits from Medicare, however, you are still responsible for your deductible and co-insurance amounts after Medicare has paid. Your signature below will serve as the authorization for payment from Medicare to Ridgeview Bariatric & Weight Loss Center. Signature Date

7 Release of Information: It may be necessary for us at some time to request medical information from your other health care providers, although we will usually ask you to get the information. However, we will need to have your signed permission to obtain these records. Please sign the form below for our possible future use. Patient Name: PLEASE PRINT Birth Date: / / Social Security # / / Maiden or other name(s): I, authorize to disclose to: Ridgeview Chaska Clinic the following medical information for the specific purpose of continuing medical care, and at the request of the patient: Consultation Reports Progress Notes Operative Reports History and Physical Discharge Summary Lab Reports Pathology Reports X-ray Reports Research Records Mental Health Records Substance Abuse records HIV Results/Testing Other (specify) Date(s) of Treatment: Health Facility Releasing Information: Information may be released to: Dr. Chute Ridgeview Bariatric & Weight Loss Center 111 Hundertmark Rd., Suite 115N Chaska, MN FAX: Signature of Patient Date I understand that Ridgeview Bariatric & Weight Loss Center will use this information only for the purpose of continued care, and managing my medical treatment I understand that Ridgeview Bariatric & Weight Loss Center will use the greatest of care to protect the privacy of my medical records I understand that I may revoke this authorization by sending a written request to no longer allow my medical records to be released to Ridgeview Bariatric & Weight Loss Center Initial Date