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Page 1 of 6 Demographics Name: _ (First, Middle Initial, Last) Date of birth: Age: Gender: Male Female Marital Status: Married Single Divorced Widowed Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: E-mail Address: Emergency Contact: Relationship: Phone: What numbers can we leave messages at and with whom? Ethnicity: (Check all that apply) African-American Hispanic Asian Caucasian Native American or Alaska Native Native Hawaiian or Pacific Islander Other Primary Care Physician Physician Name: Phone: Fax: Address: Employee Status: Full Time (at least 35 hours a week) Part-time Self Employed Homemaker Student Retired Disabled Employer Name: Occupation: Primary Insurance Information Name: Insurance _ Company Name: Subscriber s name: Gender: Male Female Date of Birth: Insurance ID Number: Group Number: Effective Date: Relationship to patient: Subscriber s employer: Secondary Insurance Information Name: Insurance _ Company Name: Subscriber s name: Gender: Male Female Date of Birth: Insurance ID Number: Group Number: Effective Date: Relationship to patient: Subscriber s employer:

Page 2 of 6 Height: Weight: Nutritional Evaluation BMI: (for office staff to complete)! 1. Are you diabetic? Yes No 2. How many years ago did you begin to have issues related to your weight? 3. How many years have you been obese? 4. What was your highest adult weight? Age you reached this weight? 5. What was your lowest adult weight? Age you reached this weight? 6. What weight loss methods have you tried? (circle all that apply) Diets Medications Behavioral Medical Weight Loss Atkins Meridia Hypnosis Physician Prescribed diet LA Weight Loss Orlistat (Xenical) Counseling Optifast Jenny Craig FenPhen Acupuncture HMR Weight Watchers Adipex Other: Other: Overeaters Anonymous HCG Injections Nutrisystem Dexatrim Bariatrix Trim Spa Other: Metabolife Stacker III Other: What is the average length of time you stayed on a diet? What was your average weight loss while on a diet? What is the average length of time you were able to maintain your weight loss? 7. Have any of your relatives had weight loss surgery? Yes No If yes, what type of surgery? What is their relationship to you? 8. Do you have a history of food allergies or intolerances? Yes No If yes, what kind? Lactose Fructose Gluten Nuts Shellfish Other: 9. Do you consume beverages containing caffeine, carbonation, and/or calories? Yes No If yes, what type and amount? 10. Do you exercise? Yes No If yes, what type and amount? 11. Check which meals you eat regularly: Breakfast Lunch Supper/Dinner Snacks 12. Provide the names of your favorite restaurants or fast food places: 13. How often do you eat meals that have been prepared away from your home kitchen? Daily Weekly 1-3 times a month Infrequently 14. Who prepares your meals in your home? 15. Who does the food shopping?

Page 3 of 6 Medication and Allergies 1. Do you have a latex allergy? Yes No If yes, what reaction does the latex allergy cause? 2. Drug Allergies Drug Name Reaction 3. List all current Medications (including vitamins, herbal supplements, aspirin, inhalers and over-the-counter medication) Drug name Dose How often do you take? Name of the pharmacy you use: Phone: Medical History (Please check any of the following medical conditions your currently have) Diabetes High Blood Pressure High Cholesterol Sleep Apnea Arthritis Gastric Reflux Asthma Urine Leakage Depression Polycystic Ovarian Syndrome (PCOS) Other: What procedure are you interested in? Gastric Bypass Sleeve Adjustable Band Why are you considering having bariatric surgery?

Page 4 of 6 Surgical History Do you have a history of: If yes, describe and provide date of surgery Heart bypass/stent Yes Heart Valve Replacement Yes Pacemaker Yes Lung Surgery Yes Breast Surgery Yes Bowel Surgery Yes Gallbladder Removal Yes Hernia Repair Yes Hysterectomy Yes Prostate Surgery Yes Hip Surgery Yes Knee Surgery Yes Gastric Surgery Yes Anti-Reflux Surgery Yes Other Yes Social History Do you live: Alone With others: Do you have a spiritual/cultural need that we need to know in order to care for you? No Yes: Do you smoke or use tobacco products? No, never No, quit months/years ago Yes, how much? months/years Do you use alcohol? No Yes, how many drinks do you have per week? Do you use any non-prescribed drugs No Yes, how much/how often/type? Family History Please check which, if any, of your family members had any of the following conditions: Condition Sibling Mother Father Grandparent Aunt/Uncle Comments Anemia Bleeding Blood clots Cancer Diabetes Gallstones Gout Heart Disease High Blood Pressure Kidney Disease Obesity Sleep Apnea Stroke

Page 5 of 6 Past Medical History (Please circle any symptom you are having presently or in the past six months) GENERAL: Weight gain, Weight loss, Fever, Chills, Sweats, Fatigue HEAD: Headaches, History of head injury, Dizziness, Fainting EYES: EARS: NOSE/THROAT: LUNGS: HEART: ABDOMEN: NEUROLOGICAL: SKIN: ENDOCRINE: BLOOD/GLANDS: EMOTIONAL: ALLERGIC: IMMUNOLOGIC LIVER: RENAL: MEN- URINARY: Jaundice (yellow color), Visual changes, Double vision, Glaucoma, Cataracts, Glasses or contacts Ringing, Hearing loss, Infections, Drainage, Pain, Hearing aid, Balance problems Sinus congestion, Nose Bleeding, Sinus Infection, Gum bleeding, Soreness, Dentures, Hoarseness or voice changes, Swallowing difficulties, Chewing difficulties Shortness of breath, Cough, Wheezing, Asthma, Coughing up blood, Tuberculosis or exposure, Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Sleep Apnea, Supplemental oxygen Chest pain (angina), Rapid heart rate, Irregular heart rate, Atrial Fibrillation, Exertional shortness of breath, Shortness of Breath lying flat, Sudden Shortness of Breath at night, Heart attack, Mitral Valve Prolapse, High Blood Pressure, Leg swelling, Palpitations, Murmurs, Rheumatic Fever, Pacemaker Stomach pains, Nausea, Vomiting, Diarrhea, Constipation, Change in bowel habits, Black stools, Blood in Stool, Reflux, Heartburn, Ulcers, Rectal pain, Rectal bleeding, Pancreatitis, Hepatitis, Jaundice, Gallbladder problems, Crohn s Disease, Ulcerative Colitis Dizziness, Loss of consciousness, Stroke, Ministrokes (TIAs), Seizures, Numbness, Weakness, and Headaches Rashes, Non healing or changing lesions, Skin cancers, Leg ulcers Thyroid problem, Heat or Cold intolerance, Type I Diabetes, Type II Diabetes, Borderline Diabetes, Gestational Diabetes, High Cholesterol/Lipids Anemia, Easy bruising, Easy bleeding, Swollen glands, Sickle cell, Lymphoma, Cancer, Coumadin usage, Blood clots Nervousness, Anxiety, Mood swings, Depression, Bipolar Disorder Hay Fever, Environmental allergies HIV, Hepatitis, Gallbladder, Lupus, Rheumatoid problems Kidney disease, Kidney failure, Stones, Dialysis Difficulty urinating, Trouble holding urine, Up at night to urinate, Excessive Thirst, Excessive urination, Blood in urine, Discharge from penis, Infections, Pain with urinating, Hesitancy, Dribbling or poor stream WOMEN: Age of first menstrual period: Last menstrual period: Number of pregnancies: Age at first full term pregnancy: Menopause since: Abortions: Do you perform breast exams: Yes/No Personal family history of breast/ovarian cancer: Last mammogram (month/year): Last gynecologic exam: Estrogen use (past or present): Breast mass, Nipple discharge, abnormal mammogram, Breast augmentation, Difficulty urinating, Blood urine, abnormal periods, Incontinence, Infections, Pain with urination, Polycystic Ovarian Syndrome (PCOS), Leakage of urine, Pelvic Prolapse

Page 6 of 6 Pain History Do you have a pain problem? No Yes If yes, is your pain new or chronic? Where is your pain located? Please describe the character of the pain (example: burning, sharp, stinging, aching) What is your level of pain on a scale from 0 to 10 (0=no pain, 10=worst imaginable) What do you do to relieve the pain? medication Rest Positioning other: If medication, what type? Does your pain relief method work? Yes No Learning Needs Highest Level of Education: Preference for learning: Reading information Hands on practice One on one discussion Language Preference: English Other: Advance Directives Do you have an Advance Directive or Living Will? Do you want information regarding Advance Directives? No Yes Patient Signature: Date: Time: FOR OFFICE USE ONLY Clinical Staff Reviewing (Physician/CRNP/RN/PA-C): Signature Date: Time:

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