*2927* For Office Use Only. BARIATRIC SURGERY CANDIDATE INFORMATION PACKET H /08;12/13;10/15 (d:\forms\hosp\.ofm) Initial appointment: Smoker:
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1 MR # NAME DOB *2927* BASSETT MEDICAL CENTER Cooperstown, NY DATE BARIATRIC SURGERY CANDIDATE INFORMATION PACKET H /08;12/13;10/15 (d:\forms\hosp\.ofm) PLEASE PRINT CLEARLY NAME: DATE OF BIRTH: MAILING ADRESS: PHONE: Cell: Home: Work: INDICATE PREFERRED CONTACT NUMBER BY CHECKING BOX. PRIMARY CARE PROVIDER: Phone number of provider: Address: MENTAL HEALTH PROVIDER: Phone number of provider: Address: INSURANCE INFORMATION NAME OF COMPANY: INSURANCE ID #: For Office Use Only NPO: Initial appointment: PHQ-9: Moorehead Score: Smoker: Provider: Epworth Score:
2 MR # DOB *2927-A* BASSETT MEDICAL CENTER Cooperstown, NY Patient Name MR # H-2927-A pg. 1 (d:\forms\hosp\.ofm) NAME DATE PLEASE PRINT CLEARLY You must answer all sections Name of person completing form: Name of person seeking evaluation: Highest Level of Education: Age at first diet: Weight at puberty: (check one) skinny normal chubby BARIATRIC SURGERY CANDIDATE INFORMATION PACKET NEW PATIENT HISTORY FORM H-2927-A 3/08;6/13;10/15 (d:\forms\hosp\.ofm) Current Height & Weight: BMI (from table included in packet): Do you consider yourself a Binge Eater (eat to the point of severe discomfort followed by severe guilt 2 or more times a week) Yes No Describe typical episode: Pregnancies: Have you ever gained weight during pregnancy that you did not loose after giving birth? Yes No What eating behavior best describe you? (check one) I eat to relieve stress I eat to comfort myself I eat to reward myself I come from a culture of eating Other (please describe) Have you ever used the following methods for weight loss? (check all that apply and provide dates - describe) Vomiting Water Pills Ipecac Laxatives Excessive Exercising Page 1 of 6
3 Patient Name MR # H-2927-A pg. 2 (d:\forms\hosp\.ofm) We will need a detailed history from you if you expect this surgery will be covered by your insurance company. At least a five-year history of dieting is required by most insurances. YOU MUST COMPLETE THIS FORM WITH SPECIFIC DETAILS REQUESTED Column #1 contains some of the most common diets used. If you have not tried these specific methods there is space to add the diets you have tried. COMPLETE ALL THREE COLUMNS FOR YOUR SPECIFIC METHODS TO THE BEST OF YOUR RECALL. Diet/Program Dates and Amount of Weight Lost # of pounds regained what period of time Example: Lean and Green diet 9/2011 through 9/12 10# 10# regained within 1 month Physician Supervised attempts Diet pills (check all that apply and complete separately) Phen/Phen, Redux, Meridia, Xenical Qysmia Other Dietitian Supervised Diabetic Education Paid Weight Loss Programs Nutri System T.O.P.S. Weight Watchers Jenny Craig Diet Fads Richard Simmons Low-Carb Atkins Diet South Beach Low Fat Diet Low Calorie Diet Other Over-the-counter products Pills Herbalife Medifast Optifast SlimFast Other Behavior Changes: Smaller portions Skipping meals No sugar No soda Page 2 of 6
4 Patient Name MR # H-2927-A pg. 3 (d:\forms\hosp\.ofm) EPWORTH SLEEPINESS SCALE What is the chance you will doze off in the following situations? (Check one that best describes you) Sitting and reading Watching TV Sitting inactive in a public place, such as a theater or meeting As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic Sum: Page 3 of 6
5 Patient Name MR # H-2927-A pg. 4 (d:\forms\hosp\.ofm) MEDICAL HISTORY Please indicate whether you have any of the following health problems: (please check yes or no) Stroke Headaches Liver Disease Seizure Disorder Gastroesophageal Gallbladder Disease Unconsciousness Reflux Disease Thyroid Disease Anxiety Heartburn Anemia Depression Asthma Diabetes Other Mental Illness Sleep Apnea Blood Disorder Deep vein thromosis High Blood Pressure Kidney Stones Pulmonary Embolism High Cholesterol Kidney Disease (blood clot) Diverticulitis Arthritis/ Gout Pneumonia Enlarged Heart Infertility Cancer Congestive Abnormal Menses Emphysema Heart Failure Urinary Incontinence Chronic obstructive Heart Attack pulmonary disease Heart Valve Disease CURRENT LIST OF MEDICATIONS (use separate sheet of paper if needed) Name Dose Frequency ALLERGIES Name Reaction Page 4 of 6
6 Patient Name MR # H-2927-A pg. 5 (d:\forms\hosp\.ofm) PREVIOUS SURGERIES Date Name of Surgery SOCIAL HISTORY Marital Status: Single Married Separated Divorced Widowed Current Living Arrangements: Alone Spouse/Significant other Friend Parent/Other Family member School aged children What is your occupation? Do you enjoy your work? Recreational activities/hobbies? Have you ever been physically or sexually abused? Do you exercise? If so, what type: Number of times per week: How long: Do you use tobacco? Never type: amt/years: Quit/when: Do you use alcohol? Never type: amt/years: Quit/when: Do you use drugs? Never type: amt/years: Quit/when: Do you use caffeine? Coffee/Tea Never type: amt/years: Quit/when: Soda Never type: amt/years: Quit/when: Chocolate Never type: amt/years: Quit/when: Page 5 of 6
7 Patient Name MR # H-2927-A pg. 6 (d:\forms\hosp\.ofm) FAMILY HISTORY SHEET Place a check in the boxes that apply to your family history. Mother Father Siblings # Children # Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Spouse Height Maximum Weight Minimum Weight State of health if living/age Cause of death/age Diabetes Heart Disease Elevated BP DVT/PE (blood clot) Stroke Arthritis/Gout Asthma Thyroid Disease Eating Disorder Mental Illness Physical/ Sexual Abuse Ulcers Kidney Disease Cancer Alcohol/Drug Abuse Do you have any questions or issues you would like to discuss with the health care provider regarding family history? Page 6 of 6
8 MR # NAME DATE DOB *2927-d* BASSETT MEDICAL CENTER Cooperstown, NY BARIATRIC SURGERY CANDIDATE INFORMATION PACKET PATIENT HEALTH QUESTIONNAIRE 9 H-2927-D 3/08;12/13 (d:\forms\hosp\.doc) Over the last two weeks, how often have you been bothered by any of the following problems? (Use to indicate your answer.) Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual. 9. Thoughts that you would be better off dead or of hurting yourself in some way For Office Coding = Total Score If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult Somewhat Very Extremely at all difficult difficult difficult Patient Signature: Date: Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an education grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.
9 MR # DOB *2927-E* BASSETT MEDICAL CENTER Cooperstown, NY NAME BARIATRIC SURGERY CANDIDATE INFORMATION PACKET QUALITY OF LIFE QUESTIONNAIRE DATE SELF ESTEEM AND ACTIVITY LEVELS H-2927-E 4/08 (d:\forms\hosp\.doc) Please make a check in the box provided to show your answer.
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