HEALTH HISTORY QUESTIONNAIRE

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Transcription:

HEALTH HISTORY QUESTIONNAIRE Date Patient Name Date of Birth Age Daytime phone ( ) Email _ Other phone ( ) How did you hear about us? My doctor Yellow pages News ad Radio/TV Friend/family Web site Other Reason for today s visit Have you had the following tests: Screening colonoscopy Yes If so, when? No Physicians Sleep study Yes If so, when? No Referring Physician Phone ( ) Primary Care Physician Phone ( ) Surgeon Phone ( ) Oncologist Phone ( ) GI Physician Phone ( ) Psychologist Phone ( ) Psychiatrist Phone ( ) Cardiologist Phone ( ) Endocrinologist Phone ( ) Nephrologist Phone ( ) Other MD Phone ( ) Allergies Yes No Initials Contrast dye / Shellfish / Iodine 1

Adhesives Dermabond Allergies (cont.) Latex Do you have any allergies to medications? Yes No If Yes, please list the drugs and type of reaction: Medications - Please list your current medications and doses below Please include over-the-counter medications & supplements, i.e. vitamins, herbals, aspirin, etc.) Name Strength Frequency I DO NOT TAKE ANY MEDICATIONS PLEASE BOX Preferred Pharmacy Medical History list any past/current problems and/or illnesses Examples: Diabetes, High Cholesterol, Hyperthyroidism or Heart Disease Obstructive Sleep Apnea Hypertension Hyperlipidemia GERD Diabetes Other (please list below) 2

Surgical History I HAVEN T HAD ANY SURGICAL PROCEDURES PLEASE BOX Examples: Appendectomy, Colon Resection, Fundoplication, TIF, Bariatric Surgery Where Date Any complications? Weight Loss History Height: Weight: BMI: How long have you been at your current weight? At what age did you become obese? What is your goal weight? What is your lowest adult weight? What year? What is your highest adult weight? What year? What type of eating style do you have? Big eater Sweets Snacker Grazer Combination of all How many times do you eat out per week? Do you exercise? Yes No If yes, how often? Medically Supervised Treatment Regiments: Please list all diets and medications for weight loss you have used and the treating physician Did you take Fen-Phen? Year: Physician: Type/Name: Year: Physician: Type/Name: Year: Physician: Other Weight Loss Attempts Program Months(s)/Years(s) Length of Participation Amount of Weight Loss Weight Watchers Exercise Calorie Control/Counting Calories Slim Fast Medifast Nutrisystems Sugar Busters 3

Jenny Craig Metabolife Optifast Xenical Adkins/South Beach Dexatrim Meridia Overeaters Anonymous LA Weight Loss Hydroxycut All Other Have you ever been treated for an eating disorder? Yes No Procedures & Testing Please indicate if you have had any of the following procedures. Yes No Where Date CT Scan Chest/Abdomen/Pelvis Ultrasound Abdomen PET scan ph & Motility studies Endoscopy Esophagram or Swallow study Labs Other: Please indicate if you have any of the following: Yes LVAD Pacemaker Defibrillator Date 4

Family Medical History Relationship Name Mother Father Sister Brother Daughter Son Unknown or No known problems Other family history (Examples: grandmother with breast cancer, aunt with heart disease) Family Member Disease Social History Yes No Do you currently smoke cigarettes? Packs/day Have you ever smoked? Year you quit Do you drink alcohol? Drinks/week Have you ever been treated for alcoholism? Have you ever used intravenous drugs? Are you currently employed? Occupation Do you have children? Do you exercise frequently? How often? 5

What is your marital status? Single Married/Partnered Divorced Widowed Other comments? Would you like to sign up for MyChart today? Manage your health, your way, using MyChart. It's an online tool designed to help you stay on track to a healthier you by providing secure anytime/anywhere access from your computer, tablet or smartphone. Decline Already in Use Enroll today Patient Signature Date Acknowledgement I am ready to pursue surgery as an option for treatment for my obesity. I agree to follow the program as prescribed and actively participate in my follow up care. I understand that I am primarily responsible for obtaining insurance approval for this procedure. I will furnish all records requested by the program in a timely manner. I will make and complete all necessary appointments to fulfill necessary requirements. I understand I am responsible for any charges not covered by my insurance. Patient Signature Date For Office Use Only: BP HR Temp SPO2 Wt Ht RR Reviewed by MD Date Entered to EMR by Date 6

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