Advanced Laparoscopic Specialists Minimally Invasive and Bariatric Surgery

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Transcription:

Advanced Laparoscopic Specialists Minimally Invasive and Bariatric Surgery Date of Visit: Health Questionnaire (Please Print) Name: _ Last First MI Date of Birth: Social Security # Driver s License #: State Address: City: State ZIP Home Phone: Mobile Phone E-mail: _ Occupation: Employer: Address: Phone: Emergency Contact Name _ Address Relationship Phone_ Health Insurance Principal Insurance Holder: Self Spouse Partner Name of Primary Health Insurance Subscriber/Group ID Policy # If you are not the primary subscriber: Name of Insured: Other Health Insurance Insured s Social Security #: Subscriber/Group ID Insured sdate of Birth Which physicians would you like us to contact regarding your treatment here? Who referred you to our practice? Primary Physician Cardiologist Pulmonologist Gastroenterologist Preferred Pharmacy

Medical History Review of Systems Do you currently have or have you in the past had any of the following? No Weight Loss No Fevers No Shaking/Chills No Nausea No Abdominal pain No Heartburn No Vomiting No Painful swallowing No Difficulty swallowing No Black, tarry stools No Bleeding per rectum No Blood in urine No Difficult/painful urination No Previous gallbladder surgery No Previous abdominal surgery No Impotence No Previous heart surgery No Urinary or prostate problems No Kidney problems No Have you ever taken steroids No Previous lung surgery (prednisone, etc?) No Diabetes No Previous organ transplant No Angina (chest pain) No Cancer No Blood clots in lungs or heart No High blood pressure No Alcoholism No Heart attack or heart disease (congestive heart failure) No Gallstones No Emphysema, Asthma or lung disease No Diverticulitis No Blood clots in legs No Thyroid problems No Have you ever taken a blood thinner like No Stomach (gastric) or duodenal Coumadin (warfarin) or Heparin? (peptic) ulcers No Liver disease, cirrhosis, or hepatitis No Do you take aspirin or ibuprofen No Disease of the pancreas No Have you had a blood transfusion No Jaundice (yellow skin) No Arthritis No Hiatal hernia No Skin diseases No Other intestinal disease No Neurologic illness No Anemia No Psychiatric illness:_ No Easy bruising or bleeding No Are you or have you been an IV drug user? No Are you currently employed? If yes, what type of work? _ No Are you exposed to any hazardous chemicals in your work or otherwise?

Family and Social History Marital status: Single Married Divorced Do you Drink alcohol? No How often: Daily Socially Occasionally Do you currently smoke cigarettes? No How many packs/day? _ For how long?_ Is there any family history of: No Cancer No Diabetes No Heart disease No Asthma or Emphysema No Stroke No Other serious health problems If yes, what are they? _ If either parent has died: Mother s cause of death was at age in what year? _ Father s cause of death was _ at age in what year? _ FEMALE PATIENTS: Date of last menstrual period: Are your menstrual periods regular? No Are you using birth control? If yes, what type: Number of Pregnancies: Number of live births: Children/Name & Age Other comments:

Medical and Surgical History Please provide a list of your medical history Type of illness Physician Additional Comments Have you had any previous surgeries? No Type of Surgery Hospital/Location Physician Are you taking any medications? No Name of Medicine/Indication Dosage Frequency Do you have any Food/Drug allergies? No If yes, to what?

Weight Reduction Programs Current Weight Weight 1 year ago Wt 5 years ago Previous Weight Reduction Efforts Type of Program Year/Duration of (Including Medications) effort Weight Loss Was all weight regained? ( Or No) Most Effective Program?_ Maximum Weight Loss Achieved? List any program/effort monitored by a Physician:

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