Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715

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1 Patient Packet Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715

2 Welcome Thank you for your interest in SSM Health Weight Management Services. Please complete the enclosed questionnaire and return it to our office. After we receive your information, you will be contacted to schedule a consultation appointment with one of our physicians. We are dedicated to providing long term treatment for the disease of obesity. Sincerely, 1313 Fish Hatchery Road Madison, WI Tuttle St. Baraboo, WI Late cancel/missed appointment policy If you miss and/or late cancel 3 appointments within a year, you will not be scheduled in the weight management department for 6 months. An appointment that is late cancelled is defined as any appointment that has been cancelled with less than 24 hours notice.

3 Date: PERSONAL INFORMATION Last name: First: MI: Address: City: State: Zip: Best number to contact: May we leave a detailed message? yes no Birthdate: Age: Sex: Primary physician: Primary physician address: Primary physician telephone: Date of your last physical exam? List other physicians you see: INSURANCE INFORMATION Insurance company: Subscriber name: Member subscriber # Group # Do you have insurance coverage for obesity care? yes no Are you interested in discussing weight loss surgery? yes no In order to determine if your insurance will cover bariatric surgery, a sleep study may be ordered during your consultation. Have you had a sleep study completed within the last 12 months? yes no Have you been diagnosed with sleep apnea? yes no Do you use a CPAP to sleep? yes no Do you snore? yes no Do you have daytime sleepiness or drowsiness? yes no Do you notice or does your partner notice you stop breathing yes no while sleeping? How do you rate your health? Poor Fair Good

4 WEIGHT HISTORY Current weight: Height: How old were you when your weight became a problem? What is your lowest adult weight? What is your highest adult weight? What is your goal weight? Have you had weight loss surgery? yes no If yes, when? Where? What makes it difficult for you to lose weight and keep it off? Have you taken prescription medication for weight loss? yes no Did you use Fen/Phen in the 1990 s? yes no Months Have you had an echocardiogram? yes no Where When List the weight loss diets you have used. PROGRAM When? How long? Pounds lost? Pounds regained? Reason stopped? Atkins Weight Watchers Slim-Fast Jenny Craig LA Weight Loss Nutri-System Liquid Diet Overeaters Annonymous Other

5 NUTRITION List one or two things you would like to change about your eating habits: In a typical week: How many meals do you eat with your family per week? How many restaurant meals do you eat per week? How many fast food meals do you eat per week? Mark the activities that trigger you to eat even if you are not hungry: meeting with friends watching TV reading attending meetings studying computer work work Mark the emotions that trigger you to eat even if you are not hungry: boredom fatique anger sadness loneliness anxiety worry happiness fear : Describe what, when, and where you eat in a typical day: MEAL Time Where Food eaten and amount Breakfast Snack Lunch Snack Dinner Snack

6 MEDICAL HISTORY Common Obesity Related yes no Type II Diabetes year diagnosed: High blood pressure High cholesterol High triglycerides Sleep apnea Using CPAP GERD/Reflux/Heartburn Fatty liver disease Gall stones Gout Heart Problems yes no Heart attack Irregular heartbeat Chest pain Chest pain with exertion Congestive heart failure Edema Respiratory Problems yes no Asthma COPD/Emphysema Shortness of breath Gastrointestinal Problems yes no Hiatal hernia Stomach ulcer Diarrhea Constipation Celiac disease Hepatities Cirrhosis Pancreatitis Genitourinary Problems yes no Leaking urine Frequent bladder infections Kidney stones Heavy menstrual bleeding Enlarged prostate Are you planning a pregnancy? Eye Problems yes no Glaucoma Musculoskeletal Problems yes no Back pain Hip pain Knee pain Foot pain Fibromyalgia Rheumatoid Arthritis Endocrine Problems yes no Type 1 Diabetes year diagnosed: Polycystic Ovarian Syndrome Gestational Diabetes Thyroid disease Skin/Hair Problems yes no Rash in skin folds Eczema Excess facial hair Psoriasis Blood Problems yes no Anemia Blood clots in legs or lungs Neurologic Problems yes no Seizure disorder Migraine headache Multiple Sclerosis Stroke TIA or Mini Stroke Pseudotumor Cerebri Cancer yes no Type year diagnosed: Mental Health Problems yes no Depression Anxiety Bipolar Disorder ADHD Obsessive Compulsive Disorder Binge Eating Disorder Anorexia Nervosa Bulimia Sexual abuse Alcohol or drug addiction History of suicide attempt

7 List other medical conditions you have: SURGICAL HISTORY Have you or a family member had problems with general anesthesia? yes no List the surgeries you have had: When? Where? FAMILY HISTORY List any biological family members who have the following diseases: Obesity Diabetes Heart Cancer SOCIAL HISTORY Are you? Married Single Divorced In a long-term relationship Widowed How many children do you have? What is your job title? Where do you work? What are your work hours? What is your highest level of education? CHANGE How ready do you feel to change your lifestyle? Please indicate on a scale of 1-10 with 1 being "not at all" and 10 being "very ready" How confident are you that you will be able to change your lifestyle? Please indicate on a scale of 1-10 with 1 being "not at all" and 10 being "very confident"

8 Do you smoke? yes no Do you drink alcohol? yes no If yes, how much per week Do you use recreational drugs? yes no (marijuana, cocaine, other) Have you ever been treated for alcohol or drug abuse? In the last month, were there any days when you did not have enough money to buy food? List the people in your household and their relationship to you: Who do you count on for emotional support? How do you cope with stress in your daily life? MEDICATIONS List the medications you are now taking: Medication Name Dose How many times per day? Why do you take it? List all vitamins, minerals, supplements, and herbs you take: Name Dose How many times per day? Why do you take it?

9 PHYSICAL ACTIVITY What is the most physically active thing you do in a day? Is there any reason you should not exercise? Do you use a cane? yes no Do you use a wheelchair? yes no Do you use a walker? yes no List daily activities you have difficulty performing ALLERGIES Do you have food allergies? yes no Please list Are you allergic to latex? yes no Are you allergic to any medications? yes no Please list Is there anything additional that you would like to talk about at your appointment? Thank you for taking the time to complete this questionnaire. We will review this information and contact you to schedule a consultation appointment. Before your appointment, please call your insurance company to review your weight management coverage. Insurance coverage varies by employer. Not all policies provide the same coverage. It is beneficial that you understand your coverage and financial responsibilities before your appointment. Please return your questionnaire to: Comprehensive Weight Management Department 1313 Fish Hatchery Road Madison, WI Fax: (608)

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