INITIAL EVALUATION FORM

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Transcription:

INITIAL EVALUATION FORM The following information is very important to your health. It will help us to give you the best possible medical/surgical care. Please take the time to complete this questionnaire. PLEASE PRINT AND USE BLACK INK. Name: (First) (Middle) (Last) Age: Date of Birth: / / Occupation: Primary Care Physician: Phone: ( ) Fax( ) Other Physician(s): Phone: ( ) Fax( ) Other Physician(s): Phone: ( ) Fax( ) Have you been referred to us? m Yes m No If yes, by whom? How did you hear about us? m Primary Care Physician m Friends/Family m Internet: Specify Website m Other: What is your primary reason for making an appointment? Are you seeking evaluation for weight loss surgery? m Yes m No At what age did you develop a significant weight problem? m Child m Teen m Adult Your highest weight? At age Are you on a restricted or special diet for any medical reasons? m No m Yes If Yes, Explain: In your opinion, what contributes to your excess weight? m Compulsive Eating m Eating too much fat/sugar m Nervous Eating m Stress m Lack of Exercise m Lack of Knowledge m Emotional Eating m Portion Size m Sweet Cravings m High Calorie Drinks INITIAL EVALUATION FORM 1/9

WEIGHT LOSS METHODS YOU HAVE TRIED: DIET LENGTH OF TIME YEAR WEIGHT LOSS m Appetite Suppressant Gum m Atkins Diet m Beverly Hills Diet m BioSlim m Dexatrim m Diabetic Diet m Diuretics m Herbal Remedies m Jenny Craig m Laxatives m Low Carbohydrate Diet m Low Fat Diet m Medifast m Meridia m MetaboLife m Metabolite m NutriSystem m Optifast m Overeaters Anonymous m Phen-Fen m Phentermine m Physician Supervised Diet m Redux m Richard Simmons Deal-A-Meal m Slim-Fast m South Beach Diet m Starvation Diet m The Grapefruit Diet m The Zone m TOPS m TrimSpa m Weight Watchers m Weight Loss Camp m Xenical m Other m Other INITIAL EVALUATION FORM 2/9

Have you or any of your family members ever had bariatric surgery? m Yes m No If yes, m Self m Mother m Father m Spouse m Brother m Sister If yes, what type of surgery was performed? m Gastric Banding m Gastric Bypass m Sleeve Gastrectomy m Don t know Other: Name of surgeon? Do you exercise regularly? m Yes m No If so, what type of exercise do you perform? How many times per week? How long do you exercise each time? Do you snore? m Yes m No Do you ever wake at night gasping for air? m Yes m No Has anyone ever told you that you stop breathing while asleep? m Yes m No Is it hard for you to fall asleep? m Yes m No Do you have or have been treated for an eating disorder? m Yes m No Has your appetite changed over the last six months? m Yes m No MEDICAL HEATLH HISTORY INFORMATION: Please indicate if you have ever suffered from any of the following conditions. Please include the name of the physician who is currently managing the condition. MEDICAL HISTORY CARDIAC m Coronary Artery Disease m MI ( Heart Attack) m Elevated Cholesterol/Triglycerides m Chest Pain m Congestive Heart Failure m Valvular Disease m Rheumatic Fever m Heart Murmur m Heart Arrhythmia (Irregular Heart Beat) m High Blood Pressure PULMONARY m Asthma m Pneumonia m Bronchitis m COPD (Emphysema) m Tuberculosis m Obesity Hypoventilation Syndrome m Pulmonary Hypertension PHYSICIAN INITIAL EVALUATION FORM 3/9

MEDICAL HISTORY PULMONARY (continued) m Sleep Apnea m Using CPAP/BiPAP Machine ENDOCRINE m Diabetes m Hyperthyroid m Hypothyroid m Adrenal (Cushing s) GASTROINTESTINAL m Reflux Disease (Heartburn) m Peptic Ulcer Disease m Gallbladder Disease m Liver Disease m Inflammatory Bowel Disease m Hiatal Hernia m Abdominal Hernia RENAL m Kidney Disease m Urinary Stress Incontinence m Kidney Stones PERIPHERAL VASCULAR DISEASE m Arterial Vascular Disease m Pulmonary Embolism m DVT (Phlebitis) m Superficial Phlebitis m Leg Ulcers m Varicose Veins CENTRAL NERVOUS SYSTEM m Stroke m Seizure m Cerebral Aneurysm m Arteriovenous Malformation m Pseudotumor Cerebri m Arterial Vascular Disease MUSCULOSKELETAL m Low back pain m Diagnosed Osteoarthritis/ DJD m Painful Joints PHYSICIAN INITIAL EVALUATION FORM 4/9

MEDICAL HISTORY MUSCULOSKELETAL (continued) m Autoimmune Disease m Gout m Gout m Fibromyalgia m Abdominal Skin/Pannus BLOOD DISORDERS m Anemia m Abnormalities with bleeding or clotting PSYCHIATRIC DISORDERS m Depression m Bipolar Depression m Anxiety m Schizophrenia m Anorexia m Bulimia CANCER Type: Treatment: Type: Treatment: PHYSICIAN OBSTETRICAL/GYNECOLOGICAL HISTORY m History of breast cancer m Pre-menopausal m Post-menopausal m Menstrual Irregularities m Polycystic Ovarian Syndrome m Number of Pregnancies: m Births: Term: Premature: Abortions: Living Children: m Have you ever had a hysterectomy? m Yes m No m If yes, indicate procedure m Vaginal m Abdominal m Have you ever had a C-Section? m Yes m No If yes, how many? m Have you ever had a Tubal Ligation? If yes, indicate procedure m Open m Laparoscopic INITIAL EVALUATION FORM 5/9

SURGICAL HISTORY: Please list all surgical procedures and year performed. If relevant specify if the surgery was done laparoscopic or open. SURGERY YEAR ALLERGY INFORMATION: Please list any known allergies and reactions ALLERGY REACTION INITIAL EVALUATION FORM 6/9

PHARMACY CONTACT INFO Name of Pharmacy: Phone: ( ) Address: MEDICATIONS Please list all prescribed and over the counter medications, vitamins and minerals you are currently using. MEDICATION DOSE TIMES PER DAY YEAR STARTED PURPOSE SMOKING/DRUG/ALCOHOL HISTORY Do you smoke cigarettes? m No m Yes, packs per day How many years? If you have smoked in the past, quit date: / / Do you drink alcohol? m No m Yes, drinks per week If yes, what type of alcohol? m Wine m Beer m Liquor m Mixed Drinks Have you ever had a problem with alcohol in the past? m No m Yes, when and for how long? Have you ever used any illicit drugs? m No m Yes, indicate drug used and how long ago? INITIAL EVALUATION FORM 7/9

PREVIOUS DIAGNOSTIC PROCEDURES Please indicate which of the following procedures you have had in the last year. Specify month in which they were performed. m EKG m Chest XRay m Lower GI m Sleep Study m Echocardiogram m Abdominal Ultrasound m Upper GI m Other m Stess Test m Colonoscopy m Pulmonary Function Test m Heart Catheterization m Upper Endoscopy m CT Scan (Body Area) FAMILY MEMBER ALIVE DECEASED DISEASE MOTHER FATHER BROTHER SISTER GRANDPARENTS CHILDREN m ADOPTED NO HISTORY OF BIOLOGICAL PARENTS Please list any specific questions or concerns that you may have so that your physician can address them at the time of your consultation: 1) 2) 3) 4) 5) 6) INITIAL EVALUATION FORM 8/9

Please describe in your own words why you are seeking surgical weight loss. (This will be part of your medical record) INITIAL EVALUATION FORM 9/9

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