SURGICAL SPECIALISTS Robotic General Metabolic Bariatric Dr. Wanda M. Good Patient Name: Date: DEMOGRAPHICS Date of Birth (mm/dd/yyyy): Age: _ Social Security #: Address: (City, State, Zip): Primary Language: Interpreter Needed: Yes No Race: Pharmacy Name: Location (Street name/city): Primary phone number: ( ) Type: (please circle) Home Cell Work phone Other Secondary phone number: ( ) Type: (please circle) Home Cell Work phone Other Email address: Best weekday(s) to be reached: (please circle) Monday Tuesday Wednesday Thursday Friday Best times to be reached on these days: _ Emergency Contact: Name: Relationship to patient: Phone number: Primary Care Physician: Phone: Practice Name: Address: Referring Physician: Phone: Practice Name: Address: Primary Insurance: Member ID: Group Number: Name of Subscriber: Subscriber DOB: Secondary Insurance: Member ID: Group Number: Name of Subscriber: Subscriber DOB: Medicare (if applicable): Medicare start date (mm/dd/yyyy): If married, spouse s Medicare start date: OR spouse s place of employment: Do you or your spouse have insurance through an employer? Yes No If yes, what insurance? LOURDES HEALTH INITIAL CONSULTATION BARIATRIC Page 1 of 8
SURGICAL SPECIALISTS Robotic General Metabolic Bariatric INITIAL CONSULTATION Patient Name: Appointment Date: MEDICAL HISTORY Duration Managed by: (physician name) OBESITY-RELATED DISEASES Type II Diabetes Hypertension Sleep Apnea CPAP or BiPAP therapy Heart Disease / Coronary artery disease Stroke Asthma (COPD) GERD (Heartburn) Elevated Cholesterol/Triglycerides Joint Pain/Disability Level Menstrual Irregularity Depression / Anxiety PAST MEDICAL HISTORY Thyroid Disease Other: Other: SURGERY -- BARIATRIC 1) Have you had any prior Weight Loss Surgery? If you checked YES, please check each appropriate box and answer corresponding questions below: Gastric Sleeve Date: Surgeon: Program: Gastric Bypass Date: Surgeon: Program: Lap Band Date: Surgeon: Program: LOURDES HEALTH INITIAL CONSULTATION BARIATRIC Page 2 of 8
SURGERY -- OTHER Please list any previous surgeries (including heart catheterizations or stents) and procedures (e.g., endoscopies, colonoscopies). Surgery / Procedure Date Surgery / Procedure Date FAMILY HISTORY Family Members (please list) Obesity Hypertension Type II Diabetes Heart Disease / Coronary Artery Disease Asthma Other: PERSONAL/SOCIAL HISTORY 1) What is your current: Height (Feet, Inches): _ Weight (Lbs.): _ BMI (office Use): Duration of Obesity: Years: Maximum Weight (Lbs.): Age (Years): 2) Occupation: Employer: Full Time Part Time Self Employed Military duty Unemployed Retired 3) Tobacco Use: FORMER If you checked YES or FORMER : How many packs per day? How many years? Type? Cigarettes Cigars E-cigarettes Hookah 4) Alcohol Use: FORMER If you checked YES or FORMER : Average number of drinks per day? per week? per month? 5) Marital Status: Single Married Divorced Widowed Separated Number of Children? Children Overweight: 6) Support for Surgical Weight Loss: 1) Spouse? N/A 2) Children? N/A 3) Parents? 4) Other? LOURDES HEALTH INITIAL CONSULTATION BARIATRIC Page 3 of 8
EXERCISE HISTORY Average total hours per week of exercise: Mon: Tues: Wed: Thurs: Fri: Sat: Sun: Exercise Preference: Walking Running Tennis Swimming Other: Barriers to Exercise: Pain Fatigue Embarrassment Lack of Interest Other: DIET HISTORY Eating Habits (Please fill in your typical dietary intake; include all foods/beverages in a 24 hour period): Breakfast: Lunch: Dinner: Snacks: Beverages: Who buys the groceries? _ Cost per week on groceries? $ Do you read food ingredients and/or nutrition labels? How many restaurant meals per week? Food Cravings (please list specific) Emotional Eating (Eating in response to stress/anxiety, anger please specify): BINGE-EATING DISORDER: Eat more food than others in a 2-hour period Unable to stop eating or unable to control what or how much is eaten Eat Rapidly Eat until stuffed Eat when NOT hungry Eat alone because embarrassed to eat amount in front of others LOURDES HEALTH INITIAL CONSULTATION BARIATRIC Page 4 of 8
DIET HISTORY CONT. COMPENSATORY BEHAVIOR Purge Fast Laxatives Excessive Exercise Other (Lays Down) PRIOR DIETING METHODS (Please check off methods, weight loss, and durations): CONSULTATIONS TIME ON PROGRAM WEIGHT LOST WEIGHT LOSS MAINTAINED (Months) (Pounds) (Months) Registered Dietician Primary Care Provider SELF DIRECTED Reducing Portions Decreasing Snacks Decrease Sweets Exercise DIETS Atkins Carbohydrates Cabbage Soup Slim Fast Other GROUP Weight Watchers Overeaters Jenny Craig Other MEDICATION (Physician supervised) Meridia Xenical Phen-fen Other: LOURDES HEALTH INITIAL CONSULTATION BARIATRIC Page 5 of 8
ALLERGIES Please list any allergies to medications and the reaction (e.g., rash, hives) or check the box if none. No Medication Allergies Medication Reaction MEDICATIONS Please list ALL medications, INCLUDING over-the counter medicines, with dosage and reason for taking. MEDICATION / DOSAGE FREQUENCY REASON FOR TAKING LOURDES HEALTH INITIAL CONSULTATION BARIATRIC Page 6 of 8
REVIEW OF SYSTEMS Please indicate any symptoms you have experienced in the last 30 days by checking YES. For any symptoms checked YES, please indicate if these are NEW or WORSENING symptoms. NO YES NEW or WORSENING NO YES NEW or WORSENING General Fever Genitourinary Painful urination Chills Increased urination Fatigue Blood in urine HEENT Blurred vision Hearing changes Congestion Sore throat Hoarseness Cardiovascular Chest pain Palpitations Respiratory Shortness of breath: At rest With physical activity Cough Musculoskeletal Generalized joint pain Joint swelling Generalized muscle aches Back pain Neurological Headache Confusion Dizziness Tingling of hands or legs Psychiatric Difficulty sleeping Anxiety Depression Gastrointestinal Abdominal pain Heartburn Trouble swallowing Nausea Vomiting Diarrhea Constipation Blood in stool Endocrine Night sweats Hot flashes Hematologic/Lymphatic Swollen glands Easy bleeding Yellowing of skin LOURDES HEALTH INITIAL CONSULTATION BARIATRIC Page 7 of 8
SURGICAL SPECIALISTS Robotic General Metabolic Bariatric How did you hear about us? Who referred you to us? Physician Referral Name: Type of Physician: Primary Care Doctor Pulmonologist Cardiologist Endocrinologist Other: _ Self-referred Family/Friend/Word of Mouth Have you seen/heard about Lourdes Surgical Specialists (including Lourdes Center for Metabolic and Bariatric Surgery Program or General Surgery) from any of the following? Radio: (station name: ) Local News/TV: (station name: ) Email/Newsletter Facebook Magazine Article: (magazine name: ) Newspaper Story Website/Search Engine (website: ) YouTube Other: LOURDES HEALTH INITIAL CONSULTATION BARIATRIC Page 8 of 8