PATIENT HISTORY QUESTIONNAIRE
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- Allan Lamb
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1 PATIENT HISTORY QUESTIONNAIRE The information requested in this questionnaire is very important. To give you the best care and to obtain your insurance approval, we must have complete answers. If you are visually or otherwise impaired and must use an assistant, please indicate his/her name below. Your name: Date of Birth: Person assisting with this form and relationship to you: Date: Age: Height: Weight: Approximately how long have you currently been at least pounds overweight? years months Diet History Approximate age when you first dieted: List the diets and weight loss programs you have tried: Program Dates Duration MD supervised Max loss Jenny Craig Nutri-Systems Weight Watchers OptiFast MediFast Prescribed Diet Pills i.e. phentermine, fastin, etc Metabolife Atkins Acupuncture Other: Please return this form to Phoebe Bariatrics Americus/Phoebe Sumter Surgical Associates 1
2 Name: List any other weight loss attempt(s) your physician supervised and documented: List any others diets and/or weight loss methods you ve tried: In your own words, please describe what you hope to accomplish and how you believe your life will change by losing weight: Medications: Be sure to list your correct dosages and strengths. Also include any over- the-counter medications, herbal and dietary supplements you take Do you take Goody/BC Powders, aspirin, NSAIDs (Motrin, Aleve, etc.) or other aspirin-based products on a regular basis? Yes No. If yes, which ones and how often? Please return this form to Phoebe Bariatrics Americus/Phoebe Sumter Surgical Associates 2
3 Name: Medical Conditions/Diseases: Have you had or do you have any of the following illnesses or conditions? If so, please briefly explain treatment you received: Heart disease: Angina Treatment: Heart Attack (MI):When: Coronary artery bypass(cabg):when: Hospital: Coronary angioplasty or stents: When: Hospital: Abnormal EKG: Treatment: Stress test Abnormal? If yes, when and where done? Palpitations/heart murmur/valve problem Treatment: Heart failure, CHF Treatment: Other: Lung/Pulmonary disease: Asthma COPD (chronic obstructive pulmonary disease) Sleep apnea If yes, CPAP or BiPAP used or recommended? What settings are used? mm water Pneumonia After surgery? yes no Gastrointestinal disease: Ulcer/bleeding ulcer Treatment: Acid reflux/gerd(gastroesphogeal reflux disease) Irritable bowel syndrome Colitis/diverticulitis Kidneys/bladder: Kidney stones Renal insufficiency/failure (chronic or acute) Urinary retention (particularly after surgery) Please return this form to Phoebe Bariatrics Americus/Phoebe Sumter Surgical Associates 3
4 Name: Kidneys/bladder continued: Urinary incontinence (leakage) Vascular (blood, blood vessels): High blood pressure Is it well controlled? High cholesterol High triglycerides Clots in legs (DVT) Clots in lungs (pulmonary embolus) Anemia Free bleeder/hemophiliac Blood transfusion in the past Venous stasis disease/ulcers Endocrine: Diabetes mellitus Year diagnosed Oral medication? Insulin injections? Date and value of last hemoglobin A1c: Under-active thyroid Nervous System: Migraine headaches Neuropathy Slipped/degenerative disk Stroke TIAs (mini-strokes) Seizure disorder Muscle/Joint/Skeletal disease: Arthritis Where affected Rheumatoid arthritis Please return this form to Phoebe Bariatrics Americus/Phoebe Sumter Surgical Associates 4
5 Name: Muscle/Joint/Skeletal disease continued: Lupus (SLE) Gout Spine disease Degenerative joint disease Fractures Fibromyalgia Infectious Disease: Staph infection Hepatitis HIV infection Tuberculosis (TB) Mental Health: Depression Bi-polar Panic disorder Schizophrenia Allergies: List any drug allergies or intolerances you know of and the effect(s) they cause: Are you allergic to (circle): tape Latex iodine Other/food allergies: Surgical History: Gallbladder removal: Open(large incision)? Laparoscopic Abdominal: Orthopedic/spinal: Head/neck/throat: Please return this form to Phoebe Bariatrics Americus/Phoebe Sumter Surgical Associates 5
6 Name: Surgical history continued: Chest/breast: Pelvic/urinary tract: Plastic surgery: Other surgery not listed above: Did you have any significant complications with any of your operations (infection, bleeding, anesthesia reaction, breathing/lung problems)? Hospitalizations: Please list any admission(s) and the approximate dates and the reasons(s) other than the surgeries listed above: Family Medical History: Please list any conditions that tend to run in your family: Did anyone in your immediate family suffer a heart attack before the age of 50? Social history: Have you ever used tobacco? Yes No What type? When did you quit? Approximately how many total years did you use tobacco? Do you use or have you ever used intravenous (IV)drugs? Do you use or have you used illegal drugs? Who resides with you in your household? Do you have any religious objections to medical treatment? Yes No If so, what? Do you drink any form of alcohol? Yes No If so, how many drinks of beer, wine or liquor have you had in the past 7 days? Past one month? Please return this form to Phoebe Bariatrics Americus/Phoebe Sumter Surgical Associates 6
PATIENT HISTORY QUESTIONNAIRE
PATIENT HISTORY QUESTIONNAIRE The information requested in this questionnaire is very important. To give you the best care and to obtain your insurance approval, we must have complete answers. If you are
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GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
PATIENT REGISTRATION INFORMATION
PATIENT REGISTRATION INFORMATION Patient Name (Last, First, Middle): Social Security #: - - Age: Date of Birth: / / Sex: Male Female Language: Marital Status: Race: Ethnicity: Hispanic or Latino Not Hispanic
Date: Referring Physician Dr. Phone: Primary Care Physician (if different) Dr. Phone:
Kuether Brain and Spine Todd Kuether, MD 19250 SW 65 th Avenue, Suite 260 Tualatin, OR 97062 501 N. Graham, MOB II #515, Portland, OR 97227 (503) 489-8111 Phone (503) 908-6800 fax kuetherbrainandspine.com