The Bariatric Center at Albany Medical Center Hospital

Transcription

1 - 1 - The Bariatric Center at Albany Medical Center Hospital PERSONAL DATA SHEET Your Mailing address, City, State & Zip Home Phone Work Phone Cell Phone Social Security Number Date of Birth Maiden (if applicable) Emergency Contact & cell phone # Health Care Proxy & Phone # RACE - circle Did a doctor REFER to you our program? (if yes, list name) or are you SELF referral Your Physicians Primary Care Physician Hispanic, white Hispanic, black Hispanic, color unknown Black, not of Hispanic origin White, not of Hispanic origin American Indian or Alaska native Asian or pacific islander unknown Clinical Nutrition Physician Other Physicians (Cardiology, Pulmonology, Gastroenterology, OB/GYN, Neurology, Ophthamology, Surgeons, Oncology etc) - 1 -

2 Please LIST your ENTIRE PAST and CURRENT MEDICAL HISTORY Include any diagnosis/reason for which you see (or have seen) a specialist, for which you have a medical device or take a medication for (such as sleep apnea, diabetes, pacemakers) Date SURGERIES AND DATES (include ALL surgeries, including minor procedures and childhood surgeries. Examples: tonsils/adenoids, appendix, gallbladder, eye surgeries, orthopedic procedures) 2

3 SOCIAL ISSUES AND HABITS Are you currently working Yes No Are you retired Yes No What is (or was) your occupation 3 Does your job require physical activity Yes No What kind: Is your job stressful Yes No If yes, what kind of stress: Are you on disability Yes No If yes for what reason: When did you go on disability: Do you require assistance with activities of daily living Yes No If YES, are you partially dependent or fully dependent Do you have a supportive person you can talk to Person s and their relationship to you Yes No What is your marital status (circle) Single in a relationship married divorced separated Do you have any children Yes No If yes, list ages: Do you live with anyone What is the highest level of education you have completed Do you consume alcohol widowed Yes No If yes: How many glasses per day: Have you had a problem with alcohol abuse in your past Yes No If yes when was last drink: Do you currently smoke Yes No If yes, What type of product: How many packs per day: How many years have you smoked: Did you quit smoking Yes No If yes was it > 1 year ago < 1 year ago Date quit: How many packs per day: For how many years: Do you use any recreational drugs currently Yes No If yes, which drugs: How often do you use it: When was the last use: Have you used drugs in the past Yes No If yes, which drugs: When was the last use: Any IV drug use Yes No Do you have any other habits or addictions Yes No (Gambling, video games, compulsive shopping etc) Have you ever been physically abused Yes No Have you ever been sexually abused Yes No Have you ever gone through counseling for any reason Yes No Please list reason: If YES, is this current Yes No Have you ever been hospitalized for depression/anxiety or any other psychological reason 3

4 4 Mother Age Alive or deceased Cancer (what type) FAMILY MEDICAL HISTORY Diabetes Blood clot (where) Stroke Heart Disease Heart Attack Obesity Other Father Siblings Siblings Siblings Siblings Grandparents Aunts or Uncles Other ALLERGIES: MEDICATIONS REACTION FOOD ALLERGIES REACTION CURRENT MEDICATIONS AND DOSES (include HERBALS and VITAMINS) 4

5 5 REVIEW OF SYSTEMS: CARDIAC YES NO IF YES PROVIDE DETAILS Heart attack (MI) Heart stent (angioplasty) Heart surgery Heart valve problems Arrythmias Chest pain Racing Heartbeat Skipping Heartbeat/palpitations High Blood Pressure Medication for high blood pressure Shortness of Breath High Cholesterol High Triglycerides Cholesterol medications at any time > 140 SBP or > 90 DBP How many? At rest? With exercise? ENDOCRINE YES NO IF YES PROVIDE DETAILS Diabetes Mellitus (Type 1&2) When was it first diagnosed: Are you on pills for it: Are you on insulin for it: Pre-diabetes or abnormal blood sugar Hypoglycemia (low blood sugar) Thyroid Problems Abnormal blood calcium level or parathyroid gland problem Osteoporosis or osteopenia Regular steroid use for any reason Taking immunosuppressants GASTROINTESTINAL YES NO IF YES PROVIDE DETAILS Previous weight loss surgery Surgery to stomach, esophagus, duodenum or pancreas Pancreatitis or pancreas problems Fatty liver Liver problems Hepatitis Gallstones diagnosed by imaging Surgery to remove gallbladder Heartburn (reflux/gerd): # days per week with symptoms: Gastric ulcer, peptic ulcer, H Pylori Stomach or intestinal bleeding Polyps in your colon Chronic diarrhea or constipation Irritable bowel syndrome Nausea or vomiting Do you take medication for it: If yes, how many did you have: When were they removed: Last colonoscopy: 5

6 6 RESPIRATORY YES NO IF YES PROVIDE DETAILS Asthma Mild moderate severe COPD or emphysema Mild moderate severe FEV1: Do you use inhalers: Have you been hospitalized for this: Are you disabled from it: Bronchitis Pneumonia Blood clots in lungs (pulmonary embolism) Are you on blood thinners: SLEEP APNEA YES NO IF YES PROVIDE DETAILS Do you snore Mild moderate severe Stop breathing during sleep Wake up with headaches Fall asleep regularly while reading or riding in a car Heartburn/reflux while sleeping Difficulty falling asleep or staying asleep Tired during the day Use CPAP or BIPAP? List your setting: Last check: Do you use oxygen When were you diagnosed: How much: MUSCULOSKELETAL YES NO IF YES PROVIDE DETAILS Do you have joint pain Any injuries to your joints Use a mobility device Limitations in activity because of joint pain Have arthritis Use anti-inflammatory or pain medication Had a joint replacement in the past Need a joint replacement Swelling in your legs or feet Varicose veins Ulcers of the leg or feet Poor circulation in legs or vascular disease Wear compressive stockings or have you been diagnosed with lymphedema Reddish/brown rash on your legs DEGREE OF PAIN 1-10 (10 being the worst) Hip Knee Ankle Feet Back Neck Arms/shoulders Hands If yes, what: NEURO PSYCHIATRIC YES NO IF YES PROVIDE DETAILS Depression or Anxiety Do you have any other mental health issues Current or past history of self- harming, cutting Does obesity contribute to it 6

7 7 NEURO PSYCHIATRIC YES NO IF YES PROVIDE DETAILS Hospitalization for any psychiatric reason Seizures Severe Headaches Migraines tension Allergy Pseudo-tumor cerebri or increased intracranial pressure Neuropathy Numbness/tingling Visual Problems Cataracts Glaucoma Do you wear glasses or contacts Due to: Near sited or Far sited Lasik or other eye surgery KIDNEY AND BLADDER YES NO IF YES PROVIDE DETAILS Spill urine while laughing or coughing? Frequent bladder infections Frequent kidney infections How many times per year: How many times per year: Kidney stones What type: Last one: Abnormal kidney function? Creatinine > 2 Are you/have you been on dialysis BLOOD AND ONCOLOGY YES NO IF YES PROVIDE DETAILS Had a bleeding problem/ bleeding after surgery Had a blood transfusion Had anemia or iron deficiency Any other blood related problem Blood clot in leg (DVT, thrombophlebitis) How was it treated: Do you take blood thinners: Do you take aspirin Have you been diagnosed with cancer Skin cancer of any type Melanoma Basal Cell Squamous Cell HAD ANY OF THESE TESTS YES NO PROVIDE DATE AND RESULTS EGD (stomach endoscopy) Heart Catherization EKG Echocardiogram (heart ultrasound) Cardiac Stress Test MRIs CT scans ( cat scans ) X-rays Ultrasounds (liver, gallbladder, ovaries) DEXA or bone scan CANCER SCREENINGS YES NO PROVIDE DATE AND RESULTS Include ABNORMAL results PSA or exam for prostate cancer Had biopsy or other procedures: Colonoscopy Pap smear Mammogram Polyps, Hemorrhoids, Diverticulosis Had LEEP, laser procedure, colposcopy Had biopsies, lumpectomies, surgery 7

8 8 FEMALES ONLY: YES NO IF YES PROVIDE DETAILS Have you had trouble conceiving or infertility Have you been pregnant Had diabetes during your pregnancy Are you still menstruating Have heavy periods/menorrhagia Experience any pain with your period Irregular periods or polycystic ovarian syndrome Surgery to remove your ovaries or uterus Use estrogen or birth control pills Do you plan on becoming pregnant in the future CURRENT DIET (list typical foods eaten at each meal and include PORTION sizes if you know them) Breakfast How many pregnancies: How many deliveries: Number of miscarriages: Menopause: Did it cause anemia: Do you take medications for it: For what reason: Lunch Dinner Snacks Between breakfast and lunch: Between lunch and dinner: After dinner: Liquids YOUR EATING HABITS YES NO IF YES PROVIDE DETAILS Do you have an eating disorder Do you binge eat Are you a stress eater Do you eat when you are bored Are you addicted to certain foods List foods: Do you eat large meals Do you eat much more rapidly than others Do you eat large amounts of food when not feeling physically hungry Do you feel guilty after overeating Do you graze or snack throughout the day Do you skip meals Are you often hungry Do you buy meals outside of the home (restaurants, work cafeterias, fast food etc) Do you wake up at night to eat Do you need to eat at night in order to fall back asleep Do you have a lack of appetite in the morning Any special diet program now Have you changed your diet in order to lose weight Why: How many meals per week: (Include breakfast, lunch and dinner) What do you eat: How many nights per week: (vegetarian, celiac, diabetic etc) How did you change it: 8

9 9 EXERCISE YES NO PROVIDE DETAILS Do you exercise now Do you have access to a Gym Type of exercise: Amount of time: # of days/week: What exercises do you do there: Do you have exercise equipment at home Did you exercise in the past What ones: What did you do: Do you have limitations to exercise Have you been in physical therapy before Do you need physical therapy in order to safely exercise now FILL OUT ALL SECTIONS BELOW IF YOU ARE INTERESTED IN LOSING WEIGHT CURRENT MEASURED HEIGHT CURRENT MEASURED WEIGHT Lowest weight while dieting & how long maintained? Highest weight? Weight at age 18? Underweight Normal Obese Weight (lbs) Pre-school Elementary High school 20s 30s 40s 50s 60s Other pertinent information: Personal Weight Loss Attempts Lbs lost Supervised Weight Loss Attempts Lbs. Lost Body for Life Bill Phillips Gloria Marshall Health Spa Dr. Phil Richard Simmons Low Carbohydrate Low Fat Calorie Counting on my own Pritikin Mayo Clinic Scarsdale Stillman Sugar Busters Slim Fast High Protein - other Atkins South Beach Diet The Grapefruit Diet Cabbage Soup Diet Hypnosis Diet Pills from MD Diet Shots from MD Diet Center Overeaters Anonymous Optifast Weight Watchers HMR Health Management Resources Nutri-Systems T.O.P.S. Jenny Craig New Direction National Weight Loss Supervised Calorie Counting Diet by Health Professionals LA Weight Loss OTHER OTHER OTHER OTHER 9

10 10 MEDICATIONS FOR WEIGHT LOSS MEDICATION and date used POUNDS LOST MEDICATION and date used POUNDS LOST Acutrim Obalan Adipex-P Orlistat Amphetamines Phendiet Anorex Phentermine Benzphetamine Phentrol Dexatrim Plegine Dexfenfluramine Pondimin Didrex Redux Ephedra Sanorex Fastin Stacker II Fenfluramine Tepanol Ionamin Tenuate Mazanor Wehless Meridia Xenical (alli) Qsymia (topiramate/phentermine) Lorcaserin (Belviq) OTHER medications not listed: Have you ever used the IF YES PROVIDE DETAILS following methods FOR WEIGHT LOSS PURPOSES Yes No Vomiting Fasting Water Pills IPECAC Laxatives Excessive Exercising Extreme Food Restrictions Other Weight Loss Surgery Information Questions YES NO IF YES PROVIDE DETAILS Do you know anyone that has had weight loss surgery Bypass Sleeve Band Where was the surgery done: Have you been to support groups for weight loss surgery Where: Which surgery are you thinking about Bypass Sleeve Band Unsure What is your motivation for surgery How did you find out about us 10