Bariatric & Laparoscopy Center

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1 Dr. Muhammad Jawad and Dr. Andre Texieria Follow the steps to get started on your weight loss journey! Step # 1 Call 800 number on back of your insurance & card ask if the procedure code below is a covered benefit under your insurance plan Sleeve Gastrectomy Gastric Bypass Duodenal Switch If you are told you have a plan exclusion that means your employer did not purchase bariatric coverage as a plan benefit and it will not be covered even if you meet medical necessity. Step # 2 If you have bariatric coverage or wish to be self-pay for your surgery please completely fill out your new patient packet and to or fax to Once we receive your new patient packet Angel will call you to schedule your appointment. What to expect during your appointment: 1. Educational group seminar (1 hour) 2. One on one consult with your surgeon 3. Insurance one on one to discuss your specific insurance requirements. Your visit may take up to 3 hours, please bring your driver s license and insurance card. Please come prepared to pay your specialist visit co-pays or co-insurance. Locations: 89 W Copeland Drive 1 st Floor Orlando, FL SE 3 rd Court, Suite 100 Ocala, FL (if you use GPS or MapQuest, make sure to spell out Court for accurate directions Page 1

2 Please print all information and use legal name printed on your insurance card. Legal Name: Last First Middle Address: Street City State Zip Social Security # Sex: M F Date of Birth: Home Number Cell Number Emergency contact: Phone Single Married Divorced Widowed Other: Employer Name: Occupation: Phone: Spouses Name: Date of birth: / / Phone: I authorize the release of protected health information to the following: Name: Relationship: Name: Relationship: Primary Care Physician: Phone: Fax: Address: Street City State Zip Insurance Information Primary Insurance Insurance Carrier: Policy # Group # Insurance Phone Number: Policy Holder (If not patient) Name: _ Last First Middle Date of Birth: / / Relationship to patient: Secondary Insurance Insurance Carrier: Policy # Group # Insurance Phone Number: I confirm that all the information listed on this packet is complete and accurate. Signature : Date : Page 2

3 Past Medical History Do you currently or have you ever had any of the following conditions? Please mark YES or NO & list the year the event or diagnosis occurred. You may also add any additional information in the COMMENTS sections. If there is more than one option in a row, circle the one that applies. Cardiovascular Disease YES NO Year Comments DO YOU CURRENTLY SEE A CARDIOLOGIST? High Blood Pressure Congestive Heart Failure Heart Disease Heart catheterization Stress test Date of last stress test? Date of last echocardiogram? Cardiac stent Heart Attack Angina Leg Swelling Blood Clots Heart Murmur location: arm OR leg OR lung (circle one) Irregular Heart Beat/Palpitations? Varicose Veins HAVE YOU EVER SEEN A CARDIOLOGIST? Diabetes High Cholesterol High Triglycerides Gout Metabolic Disease Thyroid Disease Hypo OR Hyper (circle one) Goiter OR Nodules (circle all that apply) Obstructive Sleep Apnea Respiratory Disease When was your last sleep study? Do you use CPAP Do you use O2? OR BiPAP? Circle One All the time OR just at night? Circle One Shortness of breath? Yes or No (circle one) When does it occur? Rest OR activity OR both (circle all that apply) Asthma Emphysema Page 3

4 Chronic Bronchitis Sarcoidosis Gastro-Intestinal Disease Gastro-Esophageal Reflux (GERD) Gallbladder disease Liver Disease- please give details Ulcers- please give details Diverticulosis Irritable Bowel Disease Was this diagnosed by a physician? Crohn s Disease Musculoskeletal Disease Back Pain Fibromyalgia Arthritis (location: ) Reproductive Disease PCOS (Polycystic Ovarian Syndrome) Menstrual Irregularities Genitourinary Stress urinary incontinence Frequent urinary tract infections Urinary Retention Kidney Stones Kidney Disease- Please give details Kidney Failure- Please give details Neurologic Disease Pseudotumor Cerebri Frequent headaches OR dizziness Strokes OR TIA s- (circle one) Please give details Neuropathy OR Numbness-Where? Psychological (Circle all that apply) Depression / Anxiety / Bipolar / Psychosis / Personality Disorder / Suicidal Thoughts / Bulimia / Anorexia (circle all that apply) Other (Give specifics for all YES answers.) Hernia- where? Do you use a cane or a wheel chair? Do you have areas of large hanging skin? Skin Disorders (psoriasis/eczema/acne/dermatitis) (circle all that apply) Yes No Year Comments Page 4

5 Yes No Year Comments Autoimmune disease (lupus/multiple sclerosis/etc.) (circle all that apply) Bleeding OR clotting disorders (circle one) Cancers-Please give details Infectious disease HIV TB Hepatitis (circle all that apply) Treatment? Anemia B12 deficiency / iron deficiency / other (circle all that apply) PLEASE GIVE DETAILS OF ANY MAJOR ILLNESS OR MEDIAL ISSUE NOT ALREADY ADDRESSED ABOVE: Patient Signature: Date: 5/16 Page 5

6 SURGERIES/HOSPITALIZATIONS Example - Tonsillectomy 1993 Example - Pneumonia 2001 ALLERGIES: ARE YOU ALLERGIC TO LATEX: YES NO SOCIAL HISTORY (tobacco & alcohol): Do you now or have you ever smoked: YES NO How many years did you OR have you smoked? How many packs per day did you OR do you smoke? When did you quit? Have you/do you use(d): pipe cigar e-cigarette illegal drugs-specify Do you drink alcohol? YES NO Please list the type and frequency: Have you ever experienced a drug/alcohol dependency? YES NO Give Details: Family History (please check if applicable) Diabetes Heart Disease High Cholesterol Hypertension Obesity Sleep Apnea Asthma Osteoporosis Blood Clot Stroke Father Mother Brother/Sister Child Page 6

7 Patient Pharmacy and Medication Information Name: Pharmacy Name Pharmacy Address Phone/Fax T: F: Current Medication List (please include birth control contraceptives). Special Instructions Page 7

8 Weight Loss Surgery Nutrition Assessment Please complete before your appointment with your Registered Dietitian. Date: Name: Date of Birth: Surgery Desired: Gastric Bypass Sleeve Gastrectomy Other: Surgeon Name: Dr. Jawad Dr. Teixeira Weight History: last 5 years Was there any specific event or set of events that corresponded with your weight gain? (For example: overweight since childhood, pregnancy, after an injury, loss of a loved one, divorce, marriage, etc,) How much weight would you like to lose? Diet and Weight-Loss History: Please list any weight-loss plans that you have tried in the past: Weight Loss Plan (Meal planning, weight watchers, etc.) Dates/Year Weight Lost Weight Maintained Skills Learned (Portion Control, Calorie Counting, etc.) Have you ever take any weight loss medications (Xenical (Alli, Orlistat), Meridia (Sibutramine), Phen-fen, Redux, etc.)? Please list: Are you exercising? Yes No What type of activity: How often? Please check the sweeteners you are currently using: _ Equal _Splenda _Stevia _Sugar _Honey _other artificial sweeteners _Other natural sweeteners Page 8

9 Eating Patterns/Behaviors Do you have any history of eating disorder? Anorexia Nervosa (severe restricting/starting) Bulimia/binge-purge (eating large volumes of food in a short time frame and then trying to get rid of the calories by inducing vomit, abusing laxatives, avoiding insulin injections as prescribed, or engaging in excessive exercise) Binge eating disorder (frequent episodes of eating large amounts of food in a short period of time accompanied by feelings of loss of control and remorse) Night eating syndrome (eating more than 25% of daily calories after dinner or awakening to eat 3 or more times a week) Do you eat when your become stressed? What factors make or have made weight loss and weight maintenance hard for you? (Example: time, cravings, portion control, physical inactivity, snacking). What do you usually eat throughout the day? (For example, what did you eat yesterday?) Please note if you typically skip meals. Breakfast: Lunch: Dinner: Snacks: Drinks/Beverages: How often do you eat out at restaurants:? Where? Do you drink carbonated beverages (sodas, beer, carbonated water?) and how much? Do you crave sugar/sweets/desserts? Page 9

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