University of South Alabama Center for Weight Loss Surgery
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1 Please bring this form to your fi rst appointment at the USA Center for Surgical Weight Loss University of South Alabama Center for Weight Loss Surgery For Offi ce Use Only: USASWL DEMOGRAPHIC FORM MRN Dr. Date Patient Demographic Information (Please fi ll out as completely as possible) Name Date of Birth Sex Marital Status Street Address Home Phone Address Cell or Work Phone Employer s Name Occupation Emergency Contact Relationship Employer s Street Address Street Address What type of surgery do you prefer? Please check: Gastric Bypass Gastric Band Sleeve Gastrectomy Undecided Home Phone Social Security Number Cell or Work Phone Race (optional) African-American Caucasian Hispanic American Indian Asian/Pacifi c Islander Other Primary Insurance Address Customer Service Phone Number Policy or ID Number Group and/or Contract Number Subscriber s Name Relationship to Patient Subscriber s Employment Secondary Insurance Address Customer Service Phone Number Policy or ID Number Group and/or Contract Number Subscriber s Name Relationship to Patient Subscriber s Employment Have you had any other surgical procedure for weight loss? Yes No I authorize the release of medical information necessary to process claims for health insurance and disability benefi ts, and request that payment be made directly to my physician for services rendered. A copy of this authorization will be accepted as valid as the original. Signature: 1
2 Weight and Diet History: Name Date attended seminar / / Date of fi rst USA Weight Loss Surgery Center consultation / / Body weight Height Weight history: Birth weight High school graduation Lowest weight in past fi ve (5) years Start of high school Marriage Highest weight in past fi ve (5) years For female patients: Age at fi rst period Date of last period Are you menstruating regularly? Yes No Pregnancy History Number of pregnancies Year of pregnancy Miscarriages/abortions (#) Number of live births Weight at start at delivery Obstetric complications Dietary history: Approximate age when you fi rst seriously dieted Check the programs that you have tried: Self-Directed Diet plans Group Medications Reducing portions Atkins Weight Watchers Phen-fen Decrease snacks Carbohydrates Addict Nutrisystem Redux Decrease sweets Cabbage soup Overeaters Anon Alli Exercises Sugar Busters Jenny Craig Lindora Pritikin Diet Other Meridia Slimfast Metabolife Other Xenical Other Did you ever have physician supervised diet? Yes No When? / / 2
3 Previous weigh loss surgery: Stapling Gastric Banding Gastric Bypass Biliary-pancreatic Diversion Sleeve Gastrectomy Other Dietary habits: Please list everything you have eaten in the last 24 hours Breakfast Lunch Dinner Snacks Beverages Eating habits: Have you / do you? binge eating eaten more food than others in a two (2) hour period unable to stop eating or control how much eat rapidly eat until stuffed eat alone due to embarrassment snack eating (candy) Frequently this occurs during a week Food preferences: (list on scale of 10 with 10 being most preferred) Cake/pie Fried food Other Candy Nuts Chips/snacks Pasta Chocolate Pizza Cookies Potatoes Fast food Salad dressing and type French fries Soft drinks 3
4 Do you buy groceries? Do you read labels? Do you eat in restaurants? How many times per week? List your favorite restaurants: Do you find yourself doing emotional eating in response to stress / anxiety? Do you have specifi c food cravings? If yes, please list them: Behavior and Exercise (please fi ll in or check answers): Are you able to exercise? If yes: How many times a week? What type of exercise do you do? Where do you exercise: If no: What is the most physically active thing you do? What limits your activity: (Please check) Pain in my knees Getting tired or short of breath I don t know what activities are safe for me Pain in my chest A doctor told me not to due to my illness Injury Other Medical Problems: (Please check all the medical problems that you have had in your life) Heart attack Thrombophlebitis (clots in legs) High blood pressure Thyroid problems Gastroesophageal refl ux disease (heartburn) Stomach ulcers Depression Anxiety Diabetes Arthitis/Joint pain Polycystic ovaries High cholesterol Fibromyalgia Cancer (type: ) Asthma Sleep apnea (CPAP or BiPap Pressure: ) Kidney disease Other: 4
5 Weight history: Most weight lost on a diet Name of that diet How long did you maintain that weight? Please list weight loss medications (include over the counter/herbal) that you have tried for the past five (5) years. Medication Date Date Weight When Weight When Why Did Used Started Ended Started Ended You Stop? Previous surgeries/procedures: (Please check all the surgeries that you have had. Specify the year.) Gallbladder removed Appendectomy Hysterectomy Colon surgery Year Year Year Year Tubal ligation Hernia Weight Loss Surgery Year Year Year Other Year Current Medications: (List all medications with proper dosages or bring in list if cannot fi t in columns below.) Prescription Medication: Over the counter Medication: Vitamins & Minerals: Allergies: (List anything that you are allergic to including medications or foods.) Social history: Do you smoke or have you smoked in the past? If yes, for how long and how many packs/day? Have you quit smoking? If no, are you trying to quit? If yes, when did you quit? 5
6 Do you drink alcohol?. If yes, how frequently and how many drinks / week? Are you currently experiencing any of the following problems? (Please check Yes or No) Constitutional: fevers chills Sleep: excessive daytime sleepiness snoring episodes when you quit breathing during your sleep HEENT: frequent headaches feeling like food gets stuck when you swallow Cardiovascular: chest pain difficulty breathing when lying fl at shortness of breath with exertion feeling that your heart is beating irregularly signifi cant swelling of your legs Respiratory: frequent cough frequent wheezing GI: frequent nausea frequent heartburn frequent diarrhea frequent constipation passing blood in your bowel movements frequent abdominal pain GU: painful urination blood in your urine Musculoskeletal: joint pains back pains frequent muscular pain Neurologic: dizziness seizures numbness specific areas of muscle weakness Psychiatric: depression anxiety Dermatologic: rashes non-healing wounds Endocine: frequent urination excessive thirstiness Hematologic: easy bruising frequent nose bleeds Do you use any of the following devices for assistance? (Please check) walker cane wheelchair other none Do you use assistance with any of the following activities? (Please check) eating bathing walking other none 6
7 Please describe in your own words your reason for wanting to lose weight, what you want to accomplish and what life change do you anticipate. Feel free to use the back of this page. 7
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
SURGICAL SPECIALISTS. Dr. Wanda M. Good
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MEDICAL/SURGICAL HISTORY FORM
MEDICAL/SURGICAL HISTORY FORM / / Date: / / Surgical Patients Only: Please check the weight loss procedure that you are interested in: Gastric Bypass Lap Band Undecided Revision of Previous Surgery HT
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1 General Information *Please complete in blue or black ink only* Name: Date: Address: City: State: Zip Code: Date of Birth: Email: Telephone: (Cell) (Home) (Work) Referred by: Occupation: Primary Doctor:
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Weight Loss Surgery Shaded area for office use only SELF LAST NAME FIRST MI MAIDEN CITY STATE ZIP SOCIAL SECURITY NUMBER DATE OF BIRTH AGE MALE FEMALE MARRIED DIVORCED WIDOWED SEPARATED NEVER MARRIED RACE:
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Page 1 of 7 Bariatric Patient Registration / / Today s Date Please Print Clearly Patient s First Name Middle last Current Height / Weight Mailing Address City State Zip Home Phone Work Phone Cell /Pager
Patient Information. Legal Name: First Middle Last. Street City State Zip
Patient Information Legal Name: Home Address: First Middle Last Street City State Zip Gender: (circle one) Male Female Date of Birth: Social Security #: - - mm / dd / yyyy Email: Marital Status: Primary
PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
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Single - Married - Divorced - Widow - Other Spouse s Employer (if applicable)
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Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
Medical, Gastro-Intestinal, Social Lifestyle Information Questionnaire TODAY S DATE: / / PATIENT NAME: Gender: M / F Age:
Gender: M / F Age: Employment- ( PT / FT) Unemployed / Retired / Disabled / Occupation: Reason for visit: Race: PLEASE CHECK-OFF CAUCASIAN AFRICAN AMERICAN NATIVE AMERICAN MIDDLE EASTERN HISPANIC ASIAN
HEYDARI Health Center Medically Managed Weight Loss and Wellness Center
HEYDARI Health Center Medically Managed Weight Loss and Wellness Center HEALTH QUESTIONNAIRE City: State: Zip: Home Phone: ( ) Mobile Phone:( ) E-Mail: Occupation: Employer: City: State: Zip: Phone: Ext.:
SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:
Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
New Patient Information Form
New Patient Information Form Patient Label Dear Patient: Please take a few minutes to complete this form. Your answers will help the doctors and staff plan and provide your care. If you are unsure of any