Resilient Living Solutions, LLC Kerry Brock Ferguson, Ph.D. Specializing in Bariatric and Health Psychology
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1 Resilient Living Solutions, LLC Kerry Brock Ferguson, Ph.D. Specializing in Bariatric and Health Psychology BARIATRIC SURGERY PRE-OP CLINICAL INTAKE PERSONAL DATA Patient Name: SSN: Date of Birth: Age: Sex: Male Female Marital Status: Single Married Separated Widowed Divorced Life Partnered Race/Ethnicity: Birthplace: Address: Zip: Phone: (home) (work) (cell) Height: Body Weight: Current 6 Months Ago 1 Year Ago Surgery Type (circle): Roux en Y Gastric Bypass Laparoscopic Banding Gastric Sleeve Surgeon or Surgical Group If you already have a surgery date, please note it here: FAMILY CONSTELLATION Who currently lives in your home with you?
2 SPOUSE/SIGNIFICANT OTHER Name: Age: Length of relationship: Occupation: General Health: Body Weight (circle): thin average over weight if over weight, approximately how many pounds? How would you describe your relationship? His/Her feelings regarding bariatric surgery: CHILDREN (list) Name Age Health Weight Status Provisions for post-op childcare if needed: Please list any prior marriages or significant relationships- divorce, widowed, etc.: when & nature of relationships: FAMILY OF ORIGIN In your immediate family (father, mother, brothers, sisters) is there a history of the following? (Please circle and indicate which family member.) arthritis or rheumatism high cholesterol asthma or hayfever kidney disease cancer stomach or duodenal ulcer diabetes tuberculosis heart disease alcoholism high blood pressure mental disorders 2
3 How would you describe your childhood? FATHER: Biological Adoptive Step If living, Age ; If deceased, age at and cause of death: Highest Body Weight (circle): thin average over weight if over weight, approximately how many pounds? Quality of your relationship (circle): terrible poor fair good excellent His attitude regarding bariatric surgery? MOTHER: Biological Adoptive Step If living, Age ; If deceased, age at and cause of death: Highest Body Weight (circle): thin average over weight if over weight, approximately how many pounds? Quality of your relationship (circle): terrible poor fair good excellent Her attitude regarding bariatric surgery? SIBLINGS: Number of Brothers: Full Half Step Deceased Number of Sisters: Full Half Step Deceased Name Age Health Weight Status Relationship Status On which side of the family is obesity present? (circle) Father s Mother s 3
4 EDUCATIONAL/OCCUPATIONAL HISTORY Education (circle highest level): GED High School Graduate Tech School/Certificate Associates Degree Bachelors Degree Masters Degree Doctoral Degree Field of study/certificate: Occupation: How Long: Is it Satisfying? HABITS Do you smoke? If no, did you ever smoke? How Long? Amount? Quit? (when & how) Alcohol consumption: What, how much, and when? Experimentation with drugs: What & When? History of legal problems: What & When? Caffeine consumption: What, how much, and when? Exercise: Type and frequency? STRESS Current Stressors: Weight Work Family Finances Health Other: Typical Stress Management Methods: PERSONAL/SOCIAL FUNCTIONING In what way does your weight impact you daily activities? (please circle all that apply) Decreased Stamina Increased Fatigue Exacerbation of Pain Joint Pain Mobility Personal Hygiene Sexual Relations Public Seating Self-Esteem Other: 4
5 What do you do in your down time? (circle) TV Computer Read Shop Family Friends Eat Other Is there anything you are especially looking forward to being able to do after you lose weight? Rate the amount of support you generally receive from the following: Significant Other/Spouse: None small average large (no s/o) Children None small average large (no children) Family None small average large Friends None small average large Employer None small average large Coworkers None small average large Spirituality None small average large Religious Group None small average large Other Group None small average large Specify other group: List those who are, or that you expect will be, supportive of your surgical decision. WEIGHT HISTORY Were you overweight as a: (circle all that apply) Child Pre-Teen Teen Young Adult Adult Senior Adult Specific ages/grades that you remember how much you weighed: Elementary School: age/grade weight Middle School: age/grade weight High School (entering): age/grade weight High School (leaving): age/grade weight What has been your highest weight ever (when not pregnant)? lbs. age What is your lowest adult weight ever? lbs. age 5
6 How many times have you lost 20 lbs. or more and then gained it back? 1. Never 2. Once or twice 3. three or four times 4. five times or more At what age did you try your first diet? What diet was it? Who s idea was it to diet? Circle the diets/programs/medications you have used: Acupuncture Weight Watchers Nutrisystem Pritikin Scarsdale Diet Center Jenny Craig Dexatrim Grapefruit Diet Rice Atkins Slim Fast O.A. Herbal Diets Hypnosis Tops Teeth Wiring Calorie Counting Richard Simmons Exercising Low Fat Cabbage Diet American Heart Association Radar Institute Duke University Program Inpatient Psych Program Structure House Optifast Outpatient Psych Program Carefast Medifast Meridia Zenical Fastin Phenteramine/Fenfluramine Ionamin Redux Transformations South Beach Other: FOOD INTAKE/EATING BEHAVIOR Circle the meals you typically skipped on a regular basis: Breakfast Lunch Dinner What size portions did you eat with your largest meal? Small Average Large Very Large Second helpings? Usually Sometimes Rarely Dessert? Usually Sometimes Rarely Do you frequently eat: fast food restaurant meals Circle the snack items you enjoy: cake cookies ice cream pie candy chocolate pretzels popcorn chips nuts fruit vegetables 6
7 bread cereal fast food pizza meal leftovers other When do you snack? Mid Morning Mid Day Before Dinner Evening Late Night Do you ever get up and eat during your regular sleep hours? Yes No Sometimes When are you most likely to overeat? What kinds of foods do you get cravings for? If you have ever binged, describe one of your typical binge episodes. Have you ever: thrown-up food on purpose used laxatives for weight control exercised excessively hidden food stolen food Have you ever concealed how much or what you were eating from others? From whom? Do you tend to eat when you feel: Stressed Angry Disappointed Frustrated Unhappy Lonely Nervous Bored Happy in Celebration What are your comfort foods? What eating behavior changes have you made since attending the information seminar? What is your personal weight (or size) goal? How long do you think it will take to achieve this goal? PERSONAL EVALUATION OF STRENGTHS/SHORTCOMINGS/BODY IMAGE Please list a personal strength: Please list an area of weakness (not weight, eating, or exercise): How do you think and feel about your body? What word or phrase would you use to describe your body? On a scale of 1 to 10, how would you rate your body? 7
8 1 = Hide in the back of the closet with all of your clothes on 10 = Dance in the middle of the street naked Do you avoid looking at yourself in the mirror? REASONS FOR SEEKING SURGERY Why have you decided to seek bariatric surgery at this particular time? Why now? You want the surgery for: (circle all that apply) yourself spouse/partner children grandchildren other family members friends social improvements career advancement health reasons other Does your physician support your decision? Please check the appropriate statement: My doctor recommended bariatric surgery to me. I brought the subject of bariatric surgery to my physician. MEDICAL HISTORY Are you currently being treated for any of the following? (please circle all that apply) heart disease cataracts high blood pressure cancer diabetes kidney disease liver problem high triglycerides hearing problem thyroid disease gout anemia lung disease back problems high cholesterol arthritis depression anxiety fibromyalgia NONE OF THE ABOVE Other Prescription medications: Over the counter medications: Allergies: 8
9 Surgeries: Hospitalizations: Acute/ ER Conditions & Treatment: Please list your physicians (Family & Specialists): Pain/Sleep History: (please circle all that apply) Headaches: migraine sinus chronic occasional rarely Back Pain: upper lower chronic occasional rarely Joint Pain: knees ankles shoulders hips other: Swelling: feet ankles legs other: Shortness of Breath: with exertion at rest Sleep: insomnia disturbed snore toss/turn sleep apnea wake gasping for air dry mouth & throat in AM leg cramps wake with headache drowsy in afternoon Prior Sleep Studies (when, where): PSYCHIATRIC HISTORY Outpatient Therapy/Counseling (when, who, why/diagnosis): Inpatient Treatment (when, where, why/diagnosis, voluntary/involuntary): Medications for depression, anxiety, or other psychiatric medications (past, present, who prescribed): 9
10 Substance Abuse Treatment/Hospitalizations for Detox: AA/NA History: Family Addiction History (who, when, what, duration, severity): Abuse History (who, when, what, duration, severity) Physical Abuse: Emotional/Verbal Abuse: Sexual Abuse: IS THERE ANYTHING ELSE YOU FEEL I SHOULD KNOW? Patient Signature Date 10
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The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
Physician Assisted Weight Loss Program. Patient Name: Date: Patient Address: City: State: Zip:
Physician Assisted Weight Loss Program Patient Name: Date: Patient Address: City: State: Zip: DL / ID #: Phone Number: Birthdate: Age: E-mail: Employment Information: Patient Employer: Occupation: City:
Now is the time for a trimmer, healthier you.
Weight No More! Now is the time for a trimmer, healthier you. Medical Director: Peter Ruggiero, M.D Bariatric Physical Exam Name: Age: Date: Vital Signs: BP (sitting) Pulse Height (w/o shoes) inches Weight
Phone (h) (w) (c) Address. Referred by. Birthday Age Height Weight. Ethnicity Marital Status Children. Occupation Hours in regular work week
Client Intake Form Please fill out the following questions as best you can. If there is a particular question you don t understand or want to fill out, we can discuss them at our first meeting. Thank you.
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
Legacy Weight and Diabetes Institute
General Information (Please Print Clearly) Email Address: Last Name Legal First Name M.I. Home Phone Address City State Zip Work Phone Social Security Number - - Sex Male Legacy Weight and Diabetes Institute
Riley Sleep Evaluation Questionnaire
Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us better understand your child and his or her sleep problems. Shade circles like Not
Medical History. Past Medical History
Regional Surgical Associates Dr. Adam S. Goldstein Medical History Date Name Social Security Number - - DOB Age Height Weight BMI Primary care doctor For office use only Height Weight BMI Neck Goal Ideal
CLIENT INTAKE FORM. Please describe your main reason(s) for seeking services at this time?
KARI KOKKO, MSW, RSW CLIENT INTAKE FORM Client Name: Please describe your main reason(s) for seeking services at this time? CURRENT RELATIONSHIP STATUS Single Common Law Separated Widowed Cohabitating
PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM Today s Date PERSONAL DATA Legal Name Preferred Name Age Date of Birth Height Weight Home Address City State Zip Home phone ( ) Business Phone ( ) Cell
Nutrition First Because it matters.
LuAnne Petrie Nutrition Consultant MS, RD, CDE Nutrition First Because it matters. 415 State Route 34 Colts Neck NJ 07722 info@nutritionfirstllc.com www.nutritionfirstllc.com (908) 692-4140 BACKGROUND
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC aylacarter@fullcirclepsychotherapy.org www.fullcirclepsychotherapy.org (253) 686-4681 Name (First, Middle, last): Birthdate: Age: Gender: Sexual Orientation: