Name:------------ DOB:----- Age: MRN: Weight Loss Surgery Follow-Up Data Height Weight LB WL BMI EBW %EWL How many meals per day do you eat? On average, how long does it take you to eat a meal? How many times a day do you snack? How many 8 oz. glasses of water do you drink per day? What Is your usual portion size? 0 ½ Cup 0 ¾ Cup 01 Cup D More than 1 Cup Which Beverages do you drink daily? CoffeO Tea Sod,[] Diet Soda frultjulceo Water Other Do you take any of the following supplements on a regular D Iron D Calcium 0 B12 D Multivitamin D Other basis? What type of exercise do you perform on a regular basis? How often do you exercise? How often are you experiencing any of the following symptoms: D Nausea 0 Night Cough D Reflux or heartburn D Pain when eating D Vomiting or regurgitation Have your comorbldities changed? Please use the following key: R= Resolved I= Improved U= Unchanged -- Diabetes High Blood Pressure Sleep Apnea -- GERO --- Arthritis -- Other Have any of your medications changed? If yes, please list changes: llpage
Name: DOB: Age: Please place a check in the column below that best describes how often you eat the following foods: Meat (beef OI' pork) Poult1y (chicken or turkey) Solid Fruit (e.g. apple) Raw or lightly steamed vegetables D Bread D Rice Cooked Vegetables Casseroles Pasta Eggs Yogurt, dairy or cheese Fish Fried foods Crackers or chips Soups Ice cream Alcohol Food Dally 2-3/ wk 1/ wk 1-2/ mo 1-2/ yr never Initial Evaluation for Weight Loss Surgery Employed: F/T- P/T-Self- Retired - Not Employed Height Present Weight Referring : Primary Care : Medical History ( Check all that apply) D High Blood Pressure Diabetes Hi g h Cholesterol D Arthritis Hear Disease C Snoring D Acid Reflux/ Stomach Disorders [GERD] 0 Thyroid Problem O Ankle/ leg Swelling D Depression D Urinary Incontinence High Triglycerides Other Asthma Shortness of Breath C Hiatal Hernia 2IPage
Name: DOB: A g e: Record below ma j or diets that resulted in a weight loss of 10 pounds or more. [Use additional pages as needed] Year Length of Diet Starting Wt. # of lbs, lost Length of time Type of diet weight stayed off program At what age did you develop a significant weight problem? Are there events that are related to your weight gain? If so, what are they? Are you receiving any medical or psychological services at this time? (I.e. repeated doctor visits for the same problems) D No Are you currently being treated or have you ever been treated for depression? D No Do you have or have you been treated for an eating disorder? (Anorexia, bulimia, binge-eating disorder, compulsive overeating) D No Counseling Services (type of program) Name of Psychiatrist or mental health provider 3!Page
Name: DOB: Age: Do you snore? Do you ever wake at night gasping for breath? Has anyone ever told you that you stop breathing while asleep? Do you exercise regularly? C1 No If so, what type of exercise do you perform? How many times a week do you exercise? How long do you exercise each time? In your opinion, what contributes to your excess weight? Portion sizes eating too much fat/sugar Nervous eating Lack of exercise eating o Compulsive eating o Stress Lack of knowledge about healthful eating and exercise o Emotional Have you or one of your relatives/ spouse ever had bariatric surgery? (Weight reduction surgery) If yes, what relationship are they to you? o Yes o No o Self c: Mother o Father c Spouse c Brother o Sister Other If yes, what type of procedure was performed? Gastric Banding o Roux-en-Y Gastric Bypass Distal Bypass c: Sleeve Gastrectomy don't know other Allergy Information Do you have any allergies to medication? 1:::i Yes o No If so please list below 1. What allergic reaction did you have? 2. What allergic reaction did you have? 3. 4. What allergic reaction did you have? What allergic reaction did you have? 4ll'age
Name: DOB: Age: MRN: Medical Health Information 1. Medications Please list all prescribed and over-the-counter medications that you are currently using: IVled!cation Name Dose Times per Year per day Year Started Purpose day 2, Pharmacy Information Name of pharmac y Phone Number
Name:------------ DOB:----- Age: 3, Surgical Information Type of Surgery Year Have you or a family member ever have any trouble with anesthesia? If yes, please explain what occurred 4. Medical History Please indicate if any of the following conditions have ever been significant problems for you. Please specify the year diagnosed and the physician who currently manages the problem. Cardiac: Coronary Artery Disease Ml (heart attack) If yes, treatment High Cholesterol/Triglyceride Chest Pain Congestive Heart Fallure Valvular Heart Disease (mitral valve prolapse, mitral valve regurgitation, etc.) CJ No _ Rheumatic Fever Year dlagrosed 6lrage
Name: DOB: Date: Age: MRN: Heart Murmur Irregular heart beat High blood Pressure Cl Yes Pulmonary: Asthma Pneumonia Bronchitis COPD (Emphysema) Tuberculosis Diagnosed Sleep Apnea Year dlagnosed Year dlagnosed C:J No If yes, treatment Stop breathing while sleeping 0 Yes Loud Snoring Gasping for Breath at Night Family History of Sleep Apnea Family Member Endocrine: Diabetes Mellitus Cl Yes Are you currently on Insulin? 0 Yes Hyperthyroid Hypothyroid Adrenal (Cushing's) Other Cl No D No Gastrointestinal: Reflux Disease (Heartburn) Peptic Ulcer Disease Gallbladder Disease Liver Disease _ Physiclan D No If yes, describe condition Inflammatory Bowel Dlsease (ex. Crohn's, Ulcer Colitis, etc.) Hiatal Hernia 0 Yes O No _ Cl Yes D No If yes 1 describe condition Other CJ No _ Cancer: Type/Organ(s) Affected: Treatment Do you have a history of breas t cancer? _ 71Page
Name: DOB: Age: MRN: PeriRheral Vascular Disease: Arterial Vascular Disease Pulmonary Embolism DVT ( Phlebitis} Superficial Phlebitis swelling legs 1 ankles Leg Ulcers Do you have any Ulcers currently? Varicose Veins 0 Yes 0 Yes 0 Yes 0 Yes 0 No 0 No 0 No 0 No Cl No Kidney Disease Urinary Stress Incontinence Kidney Stones 0 No D No Physlcian 0 No Obstetric/Gynecologic: Have you ever been pregnant? O No Please indicate the number of pregnancies to term Please Indicate the number of dellveries Please Indicate whether you are Menstrual cycles D None Polycystic Ovarian Syndrome or History C Yes 0 Pre-menopc1usal Irregular Cl No Post-menopausal IVlusculoske letal: lower back pain CJ Yes D No Year dic1gnosed _ Osteoarthritis/ Degenerative Joint Disease 0 Yes If yes, joints involved: C:I Neck D Shoulders D Back 0 Hips Knees 0 Ankles 0 feet D Heels Painful Joints (without osteoarthritis/ DJD} Central Nervous System: CJ Seizures D Hearing Impairments D Migraines CJ Neck Knees D Numbness of extremities Shoulders 0 Ankles D Frequent Headaches Autoimmune disease (ex, Lupus, Rheumatoid Arthritis, Connective Tissue, etc.) Gout D Back 0 feet Visual disturbances 0 Hips D Heels D No If yes, lists joints involved Have you ever had any broken bones of the face/ 0 Hands/ Wrist D Hands/ Wrist 8IPage
Name:------------ DOB:----- Age: Have you ever had any broken bones of the back/ neck? Blood Disorders: Anemia D No _ If yes, type if known------------------------------- Do you have 01 have you had any abnormalities with bleeding or clotting? 0 Yes O No If yes, explain---------------------------------- Psychiatric Disorders: Depression CJ Yes 0 No Bipolar Disorder 0 No Anxiety Schizophrenia 0 Yes Eating Disorder Other If yes to any of the above, please explain Are you currently receiving therapy or medications? 0 Yes Have you ever been hospitalized for the above conditions? 0 Yes O No Other Medical Disorders: Social/ Other History Please complete the following questions regarding your social, personal and family history. 1. Personal Information Occupation full-time D Part Time 0 Temporary D Retired 0 Disability- indicate cause Highest grade 01 level of education 9 to 11 years High School Graduate Vocatlonal/Technical Training 0 Attending College D College Graduate Religious affiliation (Optional) 0 Atheist C Catholic Do you have any children? D Graduate Degree D Jehovah Witness O Jewish C Methodist D Presbyterian C Other 0 Yes D No If yes 1 how many? What are their ages? 2, Smoking/ Drug/ Alcohol History Do you currently use tobacco? D No Have you ever used tobacco? If you answered yes to the above questions: 9IPage
Name: DOB:----- Date: Age: MRN: What type of tobacco did you use7 CJ Cigarettes Cl Cigars Pipe Chew/ Snuff What age did you start tobacco use? How many years have you used tobacco? How much do/ did you usually smoke per day? D ½ pack or less between 1 to 1 ½ packs between 1/1/2 to 2 packs 2 ½ packs+ If applicable, what age did you quit smoking? Do you currently drlnk alcohol? If you answered yes to the above question: What type(s) of alcohol are you drinking Wine Beer CJ Mixed Drinks Other Please Indicate how many drinks you currently drink. 1-2 month 3-4 month 5-6 month 7-9 month 10 month Have you been treated for an alcohol problem? D No Have you ever used any illicit drugs? (ex. Marijuana, Cocaine, Heroin, Amphetamine 1 etc.) 0 Yes If yes, please indicate what How long ago? D 6 months or less 0 6 months -1 year More than 1 year other 3. Family History In this section, please complete this chart to the best of your knowledge, If adopted and have no history of your biological family please place an X in the box Q Adopted Family History Check the box if any blood relatives have had: Colon Cancer/ Polyps Crohns Disease, Ulcerative Colitis CJ Liver Disease or Hepatitis CJ Pancreatic Cancer Gall Bladder Disease CJ Stomach or Esophagus Cancer o Diabetes Coronary Artery Disease Medical information about your biological family (i.e., ages, medical conditions, types of cancer, etc.): Father: Mother: Siblings: Children: Paternal Grandparents: 10 I P ;1 g e
Name: DOB: Age: Maternal Grandparents: 4. Previous Diagnostic Procedures Please list any laboratory diagnostic procedures within the last year. Please indicate what month they were performed. DEl<G Echocardiogram --- Stress Test --- Heart Catheterization Upper GI Lower GI Upper Endoscopy Abdominal Sonogram Colonoscopy D Sleep Study Pulmonary Function Test D Chest X-ray CT Scan (body area) Other Please list any specific question(s) that you may have about your surgical procedures in order that our doctors may become aware of your concerns prior to your appointment with them. 11 I r a g e