Gastric Sleeve Patient Profile

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Transcription:

Gastric Sleeve Patient Profile Today s date: Last name: Date of birth: First name: Occupation: Address: Primary contact number: E-mail address: Insurance: Insurance telephone number: Alternate number: Primary care physician: Insurance ID number: Secondary insurance: (if applicable) I agree that phone messages can be left for me regarding my care during the bariatric surgery process at the above numbers in the event I cannot be reached. Yes No I agree to be contacted at my email address regarding support group attendance. Yes No What prompted you to seek surgery to lose weight? Have you ever had weight loss surgery? Yes No Type: Have you ever sought bariatric surgery prior to this? Yes No If yes, what is the name of the program / physician and location? Reason you didn t proceed with surgery: Height: Dress / suit size: Weight: Shirt size: BMI: Pant size:

Weight History I have been overweight: How often do you weigh yourself? All of my life Since puberty / adolescence As an adult (Age: ) Daily Weekly Never A few times a week Monthly Other: My lowest adult weight: My highest adult weight: My goal weight: What time frame do you think is reasonable to reach your goal weight? Does your weight interfere with your daily activities? If Yes, please describe: How supportive is your family of your decision to have surgery for weight loss? (Circle one) 1 2 3 4 5 Not supportive Extremely supportive How supportive are your friends of your decision to have surgery for weight loss? (Circle one) 1 2 3 4 5 Not supportive Extremely supportive How ready are you to implement lifestyle changes to assist in managing your weight? Lifestyle changes include regular exercise, portion control, and healthier dietary choices. (Circle one) 1 2 3 4 5 Not ready Extremely ready Please describe (being as specific as you can) what you think has caused you to be overweight: 2

Which of the following contribute to you being overweight? Stress Anger / Frustration Boredom Happiness Food as a reward Being with others: (friends, co-workers, family) Genetics Sight / Smell of food Dine-in restaurants Alcohol Weight gain with pregnancy Fast food Poor planning Portion sizes Second helpings Snacking Holidays Sedentary lifestyle I enjoy food Food choices Other: Who will be your primary support person after surgery? At what age did you start your first diet? Personal Habits Do you smoke? No Yes: packs per day Do you drink alcohol? No Yes: drinks per day week month Do you use tobacco? No Yes: (amount) Do you use illicit drugs? No Yes Type: What is your occupation? What is you highest level of education? High School College Master s 3

Please provide a list of your weight loss attempts for the previous five years starting with your most recent diet. It is important that you be as detailed as possible. Once you have finished your five year history, please include any other diets or weight loss attempts you feel are pertinent to your weight loss history. A list of popular diets is provided to aid you in recalling those that you might have tried. Diet Dates Weight lost Reason for stopping Weight regain Physician or dietitian supervised? 4

Popular Diets Commercial Programs Diet Center Diet Workshop Jenny Crain LA Weight Loss NutriSystems Overeaters Anonymous (OA) Physician s Weight Loss Center Take Off Pounds Sensibly (TOPS) Weight Watchers Prescription Diet Medications Amphetamines Meridia (sibutramine) Phentermine (Fastin / Adipex / Ionamin) Xenical (orlistat) Phen-Phen Pondimin Liquid Diets Carefast Formula 3 HMR Medifast New Direction Optifast Slimfast Herbal and Non-Prescription Medications Alli Dexatrim Ephedra Hydroxcut Laxatives Metabolife Fad Diets Blood Type Diet Body for Life Cabbage Soup Diet Calorie Counting Carbohydrates Addicts Diet Dr. Phil s Ultimate Weight Loss Eat more, Weigh Less (Dr. Ornish) ediets.com Glycemic Index Grapefruit Hollywood Low Carb (Atkins) Low Fat Mayo Clinic Diet Protein Power Richard Simmons South Beach Sugar Buster s The Zone Volumetrics Therapy and Other Programs Acupuncture Behavior Therapy Diabetic Diet Exercise Programs Fasting Hypnosis Inpatient psychiatric program Previous weight loss surgery Psychotherapy Registered Dietitian 5

Exercise Habits Exercise is activity that you do above and beyond your normal daily routine. Examples would include brisk walking, running, swimming, bicycling, or playing a sport. The purpose of the activity is to increase your heart rate and burn excess calories. Activities that are performed as part of your occupation are typically not considered exercise. Have you ever been told that you should not exercise? If yes, what was the reason? How often do you exercise? Daily for minutes Type of exercise: 5-6 times a week for minutes Type of exercise: 3-4 times a week for minutes Type of exercise: 1-2 times a week for minutes Type of exercise: I rarely exercise I never exercise The type of exercise I like best is: Brisk walking Running Bicycling Swimming Playing a sport: Aerobics I lift weights: Daily 5-6 times a week 3-4 times a week 1-2 times a week I rarely lift weights I never lift weights How committed are you to incorporate an exercise regimen into your weight loss plan and lifelong weight maintenance? 1 2 3 4 5 Not committed Extremely committed Describe any barriers or concerns that you may have regarding initiating an exercise routine that provides 30 minutes of moderate physical activity most days of the week: 6

Family History Medical Condition Mother Father Sibling Grandparent Diabetes High blood pressure Stroke Cardiovascular Disease Cancer Obesity Other: If there is anything additional that you feel is important about your family s medical history, please describe: Current Medications Medication Dosage Frequency Reason for taking How long have you taken it? 7

Medical History Please check all of the medical conditions you have diagnosed with throughout your lifetime. Cardiovascular Disease Chest pain Heart attack Stroke Congestive heart failure High triglycerides / cholesterol Controlled with diet and exercise Controlled with medication High blood pressure Controlled with diet and exercise Controlled with medication Peripheral vascular disease Peripheral arterial disease Irregular heart beat Type: Pacemaker Defibrillator Heart valve disease Type: Respiratory COPD Sleep apnea CPAP Asthma TB Lung cancer Endocrine Hyperthyroidism Hypothyroidism Diabetes Type I (Juvenile onset) Type II Controlled with diet and exercise Controlled with medication Gastrointestinal GERD (reflux) Ulcers Gallbladder disease Liver disease Irritable Bowel Syndrome Crohn s Disease Hernia Hepatitis: A B C Chronic diarrhea Chronic constipation Prior bariatric surgery Gastric cancer Colon cancer Musculoskeletal Osteoarthritis (Degenerative Joint Disease) Location: Gout Fibromyalgia Osteoporosis 8

Neurological Multiple sclerosis Parkinson s Disease Seizures Migraines Renal Kidney disease Kidney stones Kidney failure Renal cancer Hematologic Iron deficiency anemia Blood clots Location: Vitamin B12 deficiency Bleeding problems Gynecological Polycystic Ovarian Syndrome Irregular periods Infertility Breast cancer Uterine / ovarian / cervical cancer Psychological Depression Suicide attempts Bipolar disorder Schizophrenia Obsessive Compulsive Disorder Alcoholism Drug addiction Hospitalization for psychological reason Please list all prior surgeries: Surgery Date Surgeon 9

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