UC Health Weight Loss Center
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- Collin Skinner
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1 Patient Medical History Form Date Name Social Security Number - - DOB Age Height Weight BMI Primary care doctor For office use only Height Weight BMI Neck Goal Ideal BMI>45 Age>38 Apnea HbA1c Insulin Male Past Medical History Please circle the appropriate response Abnormal Bleeding Blood clots in the legs Rheumatic fever Blood clots to the lungs Thyroid problems Diabetes currently Tuberculosis Diabetes while pregnant Urinary tract infections Age at onset of diabetes _ Kidney disease Diabetes control good poor Hepatitis Polycystic ovarian syndrome Do you have to take (PCOS) antibiotics before dental Problems with anesthesia work Hypertension (high blood AIDS/HIV pressure) High cholesterol or triglycerides Past Surgical History Please list all surgeries and approximate dates (year) Past Hospitalizations Please list all hospitalizations and approximate dates (year) Comorbidities office use only Page 1 of 7
2 Review of Symptoms General Infection Fevers HIV Sweats AIDS contact Fatigue TB exposure Loss of appetite Swollen glands Bloody sputum Recurring infections Persistent cough Skin infections Skin Exercise Limitations Rash Mild Acne Moderate Skin cancer Severe Senses Pain in joints Visual problems Back Hearing problems Hips Ear ringing Knees Neurological Feet Dizziness Arthritis Migraines Where? Frequent headaches Gastrointestinal Seizures Heartburn/acid reflux Strokes Stomach pains Memory loss Stomach ulcers Shaking Gastritis Numbness H. pylori infection Uncoordination Rectal bleeding Genito-urinary Liver disease Blood in urine Hepatitis or cirrhosis Vaginal infections Colitis or enteritis Stress urinary incontinence Frequent diarrhea Bladder/kidney infections Frequent constipation Prostate infections Crohn s disease Sleep apnea Stomach surgery Snoring Physical limitations Require C-pap Climbing stairs Daytime drowsiness Unusual fatigue Frequent waking at night Airline travel Choking at night Lifting from floor # of pillows used _ Use of public seating Pulmonary disease Personal care Short of breath on exertion Tying shoelaces Hay fever Playing with children Emphysema/COPD Pneumonia Gynecological (females only) Asthma Last menstrual period Aspiration/choking Pregnancies Current contraception Any chance you are currently pregnant Intending pregnancy in the next 2 years Page 2 of 7
3 Review of Symptoms (continued) Cardiovascular Psychological Heart attack Depression Congestive heart failure Feeling down Thrombophlebitis Suicidal episodes Swelling of ankles Mood swings for days at a Chest pain time Coronary heart disease Hospitalized for psychiatric Varicose veins reasons Heart murmur Use alcohol or drugs to Pulmonary embolism cope Stroke Hospitalized for substance Ever taken Fen-Phen abuse Have you had an Eating disorder echocardiogram? Vomiting to lose weight Fasting to lose weight Laxatives to lose weight Life more stable than a Medications year ago History of sexual abuse Psychiatric medications in past or present Overeat in reaction to feelings List all daily medications including over-the-counter medications and vitamins, herbs or supplements, and contraceptives Name Dosage Frequency Reason yes yes yes no no no Do you take any of the following over-the-counter medications regularly? Aspirin NSAIDS Ibuprofen Insulin Aleve Steroids yes No Page 3 of 7
4 Allergies List any known allergies or sensitivities Medication Allergy Reaction Latex Dye Iodine Tape Reaction List any allergies and sensitive to the following: allergies: Social History Marital status Single Married/Partnered Divorced/Separated Widowed Religious preference Ethnic background Education Number of people living in your home Who? What type of work do you do? What type of hobbies or activities do you do? _ Do you currently smoke? Do you drink alcohol? Have you ever smoked more than 100 Drinks per day cigarettes? How often Age started Do you use controlled Age last smoked substances? Average cigarettes per day How often Total years smoking How does your spouse, partner, family, friends, and significant others feel about your weight loss surgery? _ For adolescents only Highest grade in school GPA School performance Excellent Very good Good Fair Poor School name: History of frequent school absence Are you sexually active? Do you smoke marijuana Do you take street drugs Page 4 of 7
5 Family Medical History Please indicate if you have a family history of the following: Parent Sibling or Child Relatives cousins, aunts, grandparents, etc No Family History Don t Know Diabetes Heart Disease Hypertension Gallstones Obesity Sleep Apnea Asthma Cancer (specify type) Depression High Cholesterol Osteoporosis Age you first became overweight Weight Loss History Weight comfortably maintained Highest adult weight Lowest adult weight Please circle all that apply Grew up: overweight normal weight active in sports under wt. average wt. Weight gain after: pregnancy marriage divorce separation quit smoking moved desk job injury gradual Body For Life/Bill Phillips Gloria Marshall Health spa High protein Hypnosis Low carbohydrate Low fat Calorie counting on my own Gym membership Home gym equipment Please check all that apply. Non-Supervised Attempts Atkins Diet AYDS Mayo Clinic Diet Pritikin Richard Simmons Scarsdale Diet Stillman Diet Sugar Busters Slim Fast South Beach Diet Page 5 of 7
6 Diet Pills From MD Diet Shots From MD Diet Center Overeaters Anonymous Optifast Weight Watchers Health Management Resources (HMR) Nutri-System T.O.P.S. Jenny Craig New Direction National Weight Loss Acutrim Adipex-P Amphetamines Anorex Benzphetamine Dexatrim Didrex Fastin Fenfluramine Herbal Remedies Ionamin Mazanor Meridia Metabolife Gastric bypass (RNY or other) Stomach stapling Vertical banded gastroplasty Supervised Weight Loss Attempts Weight Loss Medications Supervised Calorie Counting Acupuncture Psychological Counseling Weigh Of Life Weight Loss Center Exercise Counseling Medifast Metrical Nutritional counseling Personal Trainer Obalan Orlistat Phendiet Phentermine Phentrol Plegine Pondimin Redux Sanorex Tepanol Tenuate Wehless Xenical Previous Weight Loss Surgery Gastric band Page 6 of 7
7 Nutrition History How many meals do you eat daily _ Do you snack between meals Do you drink soda Diet Regular How many sodas do you drink daily _ Food Preferences Candy Fast food Cookies Seafood Fried food Cakes or pies Pizza Vegetables Chocolate Steak or red meat Chips and snacks Dairy products yes No Food allergies TYPICAL DAILY INTAKE Before breakfast PLEASE RECORD THE TYPICAL TYPES OF FOODS AND THE AMOUNTS YOU EAT ON A REGULAR BASIS. Breakfast Morning break Lunch Afternoon snack Dinner After dinner Before bed Page 7 of 7
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
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
Bariatric Patient Registration / /
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
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
Please complete and return this form to be considered for evaluation
Office use only: MRN BMI Please complete and return this form to be considered for evaluation Name Date Age Date of Birth / / Sex M F Address City State Zip code Preferred Daytime Phone: ( ) - Do you have
New Patient Health Information
MEDICAL FACULTY ASSOCIATES DEPARTMENT OF GENERAL SURGERY DIVISION OF BARIATRIC SURGERY 1011 NEW HAMPSHIRE AVE, NW WASHINGTON, DC 20037 New Patient Health Information The information obtained from this
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Patient Questionnaire Patient Questionaire 40001234 Name: Sex: M F Age: Street Address: City/State/Zip: Home Phone:( ) Work Phone: ( ) Cell/Other:( ) Weight: Height: Date of Birth: Previous attempts at
Surgeons Group of Baton Rouge 7777 Hennessy Blvd. Ste. 612 Baton Rouge, La (fax)
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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
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
Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715
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PATIENT HEALTH HISTORY FORM:
PATIENT HEALTH HISTORY FORM: It is very important to know your detailed medical history information to assess your health. Obesity and its associated diseases and risk factors increase mortality and surgical
BMI: % Body Fat Ideal Body Weight: What has triggered your weight gain? What has been an obstacle to your weight loss in the past?
Patient Name: DOB: Body Weight: Height: BMI: % Body Fat Ideal Body Weight: Calculated by WMC WEIGHT HISTORY Please estimate as closely as possible for all that applies. Life Event Age Weight High School
Surgery Surgeon Date Weight Lost Weight Regained
PAST MEDICAL/SURGICAL HISTORY Please list any health condition(s) for which you are currently being treated (i.e., diabetes, sleep apnea, high blood pressure, etc.) and the date you were diagnosed. 1.
HEALTH TRANSITIONS CLINC: PART 1: Weight, Diet and Exercise History
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Patient Medical History
Date: The PMA Metabolic and Bariatric Weight Management Center 410 West Linfield-Trappe Road, Suite 100 Limerick, PA 19468 (610) 495-2338 Patient Medical History Name: Date of Birth: Age: Female Male ALLERGIES:
Name(last, first): Home Phone: Cell Phone: address: Date of birth: SSN:
36320 Inland Valley Drive Suite 201 Wildomar, CA 92595 Name(last, first): Home Phone: Cell Phone: Emergency contact/ Phone: Relationship to Emergency Contact: E-mail address: Date of birth: SSN: Would
Surgical History Please list all operations and dates:
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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New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
PATIENT REGISTRATION INFORMATION
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INITIAL WEIGHT LOSS CONSULTATION
INITIAL WEIGHT LOSS CONSULTATION Name: Date: Date of Birth: Age: Weight: Height: Weight loss goal: Name of Family Physician who will receive your progress reports: Office Address: Office Phone: Review
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Patient Name Date of Birth Age. Other phone ( ) . Other
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Date of Birth: City: State: Zip: Home phone: Who is your primary care physician?
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BayChoice Surgeons Bariatric & Laparoscopic Surgery Kenneth Hollis, M.D., FACS 11914 Astoria Boulevard Ste. 125 Houston, TX 77089 Ph. 281-482-5300 Patient Information Legal Name Last: First: M.I. Birth
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BARIATRIC SURGERY PRE-OP CLINICAL INTAKE
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Primary Care Physician Physician Name: Phone: Fax: Address:
Page 1 of 6 Demographics Name: _ (First, Middle Initial, Last) Date of birth: Age: Gender: Male Female Marital Status: Married Single Divorced Widowed Address: City: State: Zip Code: Home Phone: Work Phone:
MEDICAL HISTORY RECORD
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Centra Weight Loss Clinic Initial Appointment Questionnaire
*Please note: To provide appropriate care, forms MUST be completed prior to your initial visit. Name Date of Birth Physician Information Referring Physician / PCP (Name) Location (city, state) Date of
Weight Loss Surgery Program Application
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: