MEDICAL/SURGICAL HISTORY FORM

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Transcription:

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 WT BMI Medical History (please circle yes or no to the following questions) Has a Doctor or Health Professional ever told you that you have or treated you for any of the following? Nervous System: Stroke, mini stroke, or one-sided weakness? NO YES Chronic headaches/migraines? NO YES Seizures? NO YES Numbness or tingling in neck, arms, or hands? NO YES Heart and Circulation: High blood pressure? NO YES High cholesterol? NO YES Congestive heart failure? NO YES Heart attack? NO YES Heart valve abnormalities? NO YES Abnormal heart rhythms? NO YES Do you ever experience chest pain or palpitations? NO YES Symptoms with exercise? NO YES If yes, explain: Heart stress test? NO YES Cardiac catheterization or angioplasty? NO YES Pacemaker or implantable defibrillator? NO YES (11/07) 1 face pt. 1

/ / Date: / / Lungs and Breathing: Sleep apnea? NO YES CPAP or BIPAP machine? NO YES Have you ever had a sleep study? NO YES Asthma? NO YES Emphysema or COPD? NO YES Pulmonary embolus? NO YES How many blocks can you walk without becoming short of breath? (please circle one of the choices listed below) Less than 1 /2 block 1/2 block 1 block 1-2 blocks more than 2 blocks Liver, Gallbladder, Stomach, Intestine GERD/Acid Reflux? NO YES Heartburn? NO YES If yes, how many times per week? times/week Difficulty swallowing food or liquid? NO YES Gallstones? NO YES Pancreatitis? NO YES Cirrhosis? NO YES Stomach/duodenal ulcers? NO YES Hiatal hernia? NO YES Hepatitis (A, B or C)? NO YES Crohns/Ulcerative Colitis? NO YES Irritable Bowel Syndrome? NO YES Chronic constipation? NO YES History of GI cancer? NO YES Have you ever had a colonoscopy, barium enema, or upper endoscopy? NO YES If yes, include the date and reason why: (11/07) 2 Back pt. 1

/ / Date: / / Blood and Clotting: Are you willing to accept a blood transfusion? NO YES Anemia? NO YES Sickle cell disease? NO YES Clotting or platelet disorder? NO YES Deep Venous Thrombosis (DVT)? NO YES Have you ever been on Coumadin? NO YES Are you on any of the following?: Aspirin Plavix NSAIDS (Ibuprofen, Advil, Motrin, Naprosyn) Endocrine: Diabetes? NO YES Thyroid disease? NO YES Polycystic ovarian syndrome? NO YES Cushings Disease? NO YES Excessive thirst, urination, or hunger? NO YES Visual changes (wavy lines, spots)? NO YES Changes in body temperature (very cold or hot)? NO YES Miscellaneous: Depression? NO YES Schizophrenia? NO YES Other psychiatric disorder? NO YES Joint pain (hip, knee, ankle, lower back)? NO YES If yes, circle the areas that are affected Lower back hip knee ankle Urinary stress incontinence? NO YES If yes, how many pads do you use per day? pads/day Kidney stones and/or other kidney disease? NO YES (11/07) 3 face pt. 2

/ / Date: / / Miscellaneous continued: HIV? NO YES Autoimmune disease (rheumatoid arthritis, lupus, etc)? NO YES If yes, please explain: Pregnancy History: How many times have you been pregnant? How many times have you delivered? Have you ever had a c-section? NO YES (If yes, how many)? Complications following delivery or c-section? NO YES Problems during pregnancy (increased BP or blood sugar)? NO YES Have you ever had a tubal ligation? NO YES Have you ever had problems becoming pregnant? NO YES If yes, please explain: Surgical History: Have you ever had prior surgery? NO YES Have you ever had weight loss surgery? NO YES If yes, list all surgeries that you have had and the year in which they occurred: (11/07) 4 Back pt. 2

/ / Date: / / Surgical History continued: Have you ever experienced any of the following after surgery? Blood clot(s)? NO YES Abnormal bleeding? NO YES Problems with anesthesia? NO YES If yes please explain: Difficulty healing? NO YES If yes please explain: Drug Allergies? NO YES If yes, describe the reaction you had: Social History: Current smoker? NO YES If yes, how much do you smoke (pack(s)/day): pack(s)/day How many years have you smoked: years Past smoker? NO YES If yes, indicate the number of months since you quit: months Drink alcoholic beverages? NO YES If yes, indicate the number of drinks/week: drinks/week Current IV drug use? NO YES Past IV drug use? NO YES Do you live alone? NO YES Do you use a wheelchair or walker? NO YES Occupation: (11/07) 5 face pt. 3

/ / Date: / / Family History: (parents and siblings): Check here if your family history is unknown Obesity NO YES High Cholesterol NO YES Bleeding NO YES Diabetes NO YES High blood pressure NO YES Heart disease NO YES Heart Attack NO YES DVT or thrombosis NO YES Cancer NO YES Anesthesia difficulty NO YES Sleep apnea NO YES Asthma NO YES Current medications: Please include all prescriptions and over the counter medications, herbs and vitamins. (You may bring a separate list) Medication Dose Frequency (11/07) 6 back pt. 3

/ / Date: / / Please check all previous weight loss program or medications you have tried: Program Date Weight (lost or gained) Length of participation Weight Watchers Overeaters Anonymous Liquid diets (optifast) Diet pills (phen-fen, redux) Diet pills (meridia, xenical) Nutrisystem Jenny Craig OTC diet pills Nutritionist/dietitian Surgery Other (11/07) 7 face pt. 4

/ / Date: / / Surgical Candidates Only: PERSONAL STATEMENT PLEASE TELL US IN YOUR OWN WORDS WHY YOU ARE PURSUING WEIGHT LOSS SURGERY GIVE THREE DIFFERENT REASONS FOR ENTERING THE PROGRAM AND INCLUDE ANY PERSONAL GOALS. PLEASE USE ADDITIONAL PAPER IF NECESSARY. (11/07) 8 Back pt. 4

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