Weight Loss Surgery Shaded area for office use only SELF LAST NAME FIRST MI MAIDEN CITY STATE ZIP SOCIAL SECURITY NUMBER DATE OF BIRTH AGE MALE FEMALE MARRIED DIVORCED WIDOWED SEPARATED NEVER MARRIED RACE: WHITE AFRICAN AMERICAN HISPANIC ASIAN NATIVE AMERICAN/ALASKAN NATIVE OTHER CAN BE REACHED OR MESSAGE LEFT AT HOME # DURING THE DAY? YES NO HOME PHONE# CAN BE REACHED OR MESSAGE LEFT AT WORK # DURING THE DAY? YES NO WORK PHONE# CAN BE REACHED OR MESSAGE LEFT AT CELL # DURING THE DAY? YES NO CELL PHONE# DO YOU WISH TO RECEIVE COMMUNICATION VIA E-MAIL? YES NO EMAIL: EMPLOYER SPOUSE LAST NAME SOCIAL SECURITY NUMBER EMPLOYER YOUR PRIMARY CARE PHYSICIAN FAMILY PHYSICIAN DATE OF LAST VISIT PHONE FIRST DATE OF BIRTH FAX PHYSICIAN WHO REFERRED YOU TO US REFERRING PHYSICIAN PHONE FAX OCCUPATION ARE YOU ALREADY A PATIENT OF / WORKING WITH: The Center for Lifestyle Medicine YES NO Dr. Courtney Noble YES NO Page 1 of 6
Name: Weight Loss Surgery Date: AUTHORIZATION FOR RELEASE OF INFORMATION I authorize the physician and outpatient staff in attendance on this case to release medical information to the pertinent insurance company (s) or third party carriers and request payment to be made directly to the billing entity. I understand that I am financially responsible for any balance not covered by the insurance carrier (s). I also request that payment of benefits from my policy (Medigap/other be paid directly to the billing entity until otherwise notified. Signature Signature of parent (if minor) PRIMARY INSURANCE COMPANY INSURANCE CO. NAME CITY STATE ZIP POLICYHOLDER S NAME RELATIONSHIP TO PATIENT POLICY NUMBER CUSTOMER SERVICE PHONE NUMBER PROVIDER INQUIRY/PRECERTIFICATION PHONE NUMBER CONTACT PERSON IS GASTRIC BYPASS AND/OR LAP-BAND FOR MORBID OBESITY A COVERED BENEFIT? YES NO SECONDARY INSURANCE COMPANY NAME CITY STATE ZIP POLICYHOLDER S NAME RELATIONSHIP TO PATIENT POLICY NUMBER GROUP/PLAN NUMBER CUSTOMER SERVICE PHONE NUMBER PROVIDER INQUIRY/PERCERTIFICATION PHONE NUMBER CONTACT PERSON NAME: Page 2 of 6
SURGERY OPTIONS Please circle the surgery below that you are interested in having: Weight Loss Surgery Gastric Bypass (Open or Laparoscopic) Lapband Revision MEDICAL INFORMATION Do you have, or have you had, any of the following: Diabetes High blood pressure High cholesterol Chest pain or angina Heart Failure Hear attack, when? Heart disease Asthma Frequent constipation or difficulty with evacuation Frequent diarrhea or fecal incontinence Crohn s disease colitis Irritable bowel syndrome Hernia, what Kind: Blood clot or clotting disorders: where? When? Bowel incontinence Headaches, how often: Sleep apnea Do you use (circle) CPAP BiPAP Thyroid disease Do you use Oxygen Yes No Fatty liver disease How many Liters? Hepatitis B or C: How many hours/day do you use oxygen? HIV Cancer, what kind: When: Treatment (circle) Surgery Radiation Chemotherapy Women: last menstrual cycle, Date: Menopause: Yes No Arthritis, joint pain Gallbladder trouble Lupus Polycystic ovarian syndrome (PCOS) Heartburn, indigestion/gerd Use wheelchair or scooter: Yes No Stomach ulcers I agree to a blood transfusion, if needed. Yes No (please circle choice) How many hours per day? How far do you walk in a normal day? How many steps can you climb?: How many steps do you climb daily? Refusal of medically necessary blood products may affect your ability to have weight loss surgery. estern University Other: Page 3 of 6
Weight Loss Surgery NAME: PREGNANCIES, INCLUDING DATE Indicate if full term, premature, C-section, etc. DATE Indicate if full term, premature, C-section, etc. DATE SURGICAL INFORMATION SURGERY On the diagram to the right, please indicate the location of any surgical incisions (scars from surgeries) that you have. Allergies: Are you allergic to any drug, food, or substance? If yes, what happens when you take or are exposed to it (example: penicillin ---- get a rash) Tobacco products: Do you use any tobacco products? YES NO If yes, what kind? how often? what year did you start? Quit date: Alcohol: How much of the following do you drink per week? Mixed drinks (1 oz/drink) Beer (12 oz) Wine (6 oz glass) Page 4 of 6
NAME: Weight Loss Surgery MEDICAL INFORMATION What medications do you take on a regular basis? Please list your prescription medications first, then any over-the-counter (e.g., Tylenol, Ex-Lax, etc), herbal (e.g., St. John s Wort, glucosamine-chondroitin), or vitamin-mineral supplements (e.g., Calcium, One-A-Day). Prescription Name Dosage (e.g., mg ) Frequency (times per day) Why do you take it? Over the Counter/ Vitamin/Herbal Name Dosage Frequency Why do you take it? Page 5 of 6
Weight Loss Surgery NAME: Current weight: Lowest weight: Height: DIET HISTORY Weight at 18 years of age: Highest weight: Goal (desired) weight: 1. Record ALL weight loss attempts, especially professionally supervised (physician, and/or registered dietitian) programs. 2. Start with your first diet and proceed until the most recent one. 3. If you were on weight-loss medications (e.g., Adipex, Redux, Meridia, Xenical), what type of food plan were you following (e.g., 1200-calorie, low-fat, low-carbohydrate, etc) in addition to taking the drug? Year Age at start of diet How long were you on this diet Weight at start of this diet Weight lost on this diet What kind of diet were you on? Doctor or dietitian who supervised this diet Page 6 of 6