PATIENT HEALTH HISTORY FORM:
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1 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 complications. We rely on the information you provide; therefore it is imperative for safety and insurance purposes that a detailed medical history be completed. Metabolic and Bariatric Surgery has strict requirements. NO tobacco products are permitted for 8 weeks before surgeryo This gives your lungs a chance to better provide oxygen to your blood, which can help decrease the risk of infection, pneumonia, and especially improve wound healing. Second hand smoke is also irritating to the lungs. o Causing the above risks and should be avoided. We will not operate on any patient that is an active smoker. o May be require to take a laboratory test to confirm you are smoke free. PATIENT STATEMENT I am aware that Bariatric or Weight-loss surgery is not a quick fix but rather a tool for controlling weight, combined with exercise and proper nutrition. I am aware that I will be expected to follow up post op on a regular basis, and be required to take vitamins, and supplements for the rest of my life. I am also aware that reversal of this surgery is not recommended. The information on my medical history form is true and correct to the best of my belief. Height: Weight: Birth date: Name: Patient s signature: Date: Employment status: Full Time/Part Time/Unemployed/Retired I am interested in Please circle one: Sleeve Gastrectomy/Gastric Bypass/ORBERA/Unsure How did you hear about us?
2 WEIGHT LOSS HISTORY It is CRITICAL and IMPERATIVE to document any evidence of previous weight loss attempts which is a requirement from the insurance companies. Please fill out the details and include the dates, length of time of each diet, and outcomes to the best of your knowledge. Start with the most current. Weight lost on this diet:, Type of Diet/ Weight Loss Program:_, Weight lost on this diet:, Type of Diet/ Weight Loss Program:_, Weight lost on this diet:, Type of Diet/ Weight Loss Program:_, Weight lost on this diet:, Type of Diet/ Weight Loss Program:_, Weight lost on this diet:, Type of Diet/ Weight Loss Program:_, Weight lost on this diet:, Type of Diet/ Weight Loss Program:_, Weight lost on this diet:, Type of Diet/ Weight Loss Program:_, EXAMPLES OF WEIGHT LOSS METHODS: 1. Supervised Diets: Medifast, Optifast, Nutri System, Weight Watchers, Overeaters Anonymous 2. NON-Supervised Diets: Slimfast, Calorie counting, Low Fat, Atkins diet, Hypnosis. 3. Weight Loss Medications.
3 CARDIOVASCULAR Heart problems: YES / NO, If yes please describe; Chest pains: YES /NO If yes; How Long? How do you relieve the chest pain? Previous Heart Attack: YES / NO If yes when? Did you require surgery? Heart Stents? How many? How long ago? High blood pressure: YES / NO Are you on medication if so what? Previous Blood Clot or PE: YES / NO, if yes when? Shortness of Breath: At rest? YES / NO With activity? YES / NO, How long before getting short of breath? High cholesterol: YES / NO High triglycerides: YES / NO Feel tired all the time: YES / NO EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the situations described below, in contrast to just feeling tired? This refers to your usual way of life in recent times. Use the following scale to choose the most appropriate number for each situation. 0= would never doze 1= slight chance of dozing 2= moderate chance of dozing 3= high chance of dozing SITUATION Sitting and Reading Watching TV Sitting, inactive, in a public place (e.g: a theatre or a meeting) As a passenger in a car for over an hour without a break Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic TOTAL CHANCE OF DOZING Score: 0-10: Normal Range 10-12: Borderline 12-24: Abnormal Have you had a Sleep Study Test? Yes/No or Are you scheduled for a Sleep Study Test? YES / NO Do you currently use or have you previously been prescribed a CPAP or BiPAP machine? Yes/No
4 DIABETES AND ENDOCRINE SYSTEM Have you been diagnosed with Diabetes Mellitus? YES / NO, if yes what type? Type 1 / Type 2 If yes to the above questions please answer the following. When your diabetes was first diagnosed? Are you taking oral medications? YES / NO If yes what? Are you taking insulin? YES / NO Does your diabetes resolve with weight loss? YES / NO Have you been told you are Pre-diabetic or borderline diebetic? YES / NO Have you ever had Gestational Diabetes? YES / NO How old were you at the time? History of Hypoglycemia? YES / NO Thyroid problems (requiring medication) Hyperthyroid? YES / NO Hypothyroid? YES / NO GASTROINTESTINAL Do you have gallstones that was diagnosed by ultrasound? YES / NO Have you had your gallbladder removed? YES / NO, if yes, laparoscopically or open. Have you had stomach ulcers? YES / NO Have you taken medicine for ulcers? YES / NO Do you or have you had heartburn? YES / NO How often do you have heartburn,, and do you take medications for it? YES / NO Asthma: Last attack? COPD: Last attack? Bronchitis: Last attack? Pneumonia: Last attack? YES or NO YES or NO YES or NO YES or NO RESPIRATORY Have you ever had Blood clots in lungs? YES / NO, if yes when? Have you ever had Blood clots in legs? YES / NO, if yes when?
5 MUSCULOSKELETAL MILD MODERATE SEVERE Hip Pain Knee Pain Ankle Pain Feet Pain Back Pain Neck Pain Arthritis Do you have swelling of your legs? YES / NO Do you have swelling of your feet? YES / NO Do you have varicose veins? YES / NO Have you had ulcers of the leg? YES / NO Do you use anti-inflammatory medicine? YES / NO, if yes what, Do you use pain medicine? YES / NO, if yes what, and how often, KIDNEY & BLADDER Do you have renal insufficiency? YES / NO Renal Failure? YES / NO Have you had bladder or kidney infections? YES / NO Have you had kidney stones? YES / NO Have you ever had a bleeding problem? YES / NO Have you ever had low platelets? YES / NO Have you ever had a blood transfusion? YES / NO BLOOD NEURO-PSYCHIATRIC Depression/Anxiety because of obesity? YES / NO Requiring medication? YES / NO, If yes what kind? Seizures YES / NO Requiring Medication? YES / NO, If yes what kind? Severe headaches? YES / NO Requiring Medication? YES / NO, If yes what kind? Visual problems? YES / NO Been in counseling? YES / NO Eating disorder? YES / NO Bulimia? YES / NO Anorexia Nervosa? YES / NO
6 Allergies to Medicine? ALLERGIES What was the reaction? _ Allergies to Food? What was the reaction? Have you ever had reaction to anesthesia or has a family member had a reaction? YES / NO Are you allergic to Latex products? YES / NO PAST SURGICAL HISTORY We need a complete list of all your previous surgeries. Please list the type of surgery below: Tonsillectomy: Cholecystectomy (gallbladder removal): Appendectomy: Hysterectomy (removal of uterus): Cesarean Section (C-section): Oophorectomy (removal of ovary): Hiatal Hernia surgery: Cardiac Surgery YEAR Other Surgeries: PLEASE LIST: SOCIAL HISTORY Do you smoke? YES / NO If yes, what kind? How often? What year did you start? When did you quit? How much alcohol do you drink per week? Mixed drinks; Beer; Wine; Have you ever used street drugs? YES / NO, if yes, what kind? When was the last time you used? EDUCATION: What is your highest level of education? Some High School High School / EGD College Post-Graduate SUPPORT: Does your family support your efforts to lose weight? YES / NO Does your spouse / significant other supports your efforts to lose weight? YES / NO
7 Are they overweight or obese? YES / NO Do your children support your efforts to lose weight? YES / NO Are they overweight or obese? YES / NO Describe your work and home life (family members, etc) Name a close, supportive friend or family member who I can talk to: FAMILY HISTORY (Parents, Grandparents, Brothers, Sisters) Mother Father Sibling Aunt/Uncle Grandparent Obesity Diabetes Heart Disease High Blood Pressure Cancer Arthritis Death Cause of death of any family member: Has any member of your family suffered from Blood Clots or Pulmonary Embolism? YES / NO If yes, please describe: FOR WOMEN ONLY Any pain with period? YES / NO Have you ever been diagnosed with polycystic ovarian syndrome? YES / NO Have you had problems conceiving? YES / NO How many pregnancies have you had? YES / NO How many children do you have?
8 MEDICATIONS (Report name, dose, and frequency and what you are taking it for) MEDICATIONS DOSAGE FREQUENCY CONDITION
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*521634* Sleep History Questionnaire. Name of primary care doctor:
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Dr. Edmund P. Chute, MD
Date attended class: Dr. Edmund P. Chute, MD Procedure of choice: Laparoscopic Roux-en-Y gastric bypass Sleeve Gastrectomy Unsure Personal Information: First Name: Middle Initial Last Name Social Security:
PLEASE COMPLETE THE ENCLOSED PAPERWORK PRIOR TO YOUR FIRST VISIT
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Sleep Center New Patient Questionnaire
For office use only Appt date: Sleep Center Clinician: Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 #1 respiratory hospital
Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License:
MEDICAL WEIGHT LOSS PROGRAM. Medical History Form
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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
PULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN 1305 West 34 th Street, Suite 400, Austin, TX Phone: Fax:
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Gastric Sleeve Patient Profile
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Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
Patient Name Date of Birth Age. Other phone ( ) . Other
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
Sleep History Questionnaire
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SLEEP QUESTIONNAIRE. BMI: (Risk if >30) Neck Circ: (Risk if: Male >16.5, Women >15)
SLEEP QUESTIONNAIRE Name: Date: Please place a check mark next to any of the following symptoms you are experiencing: Difficulty falling asleep and/or insomnia Excessive daytime sleepiness and/or fatigue