Bariatric Patient Registration / /

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Transcription:

Page 1 of 7 Bariatric Patient Registration / / Today s Date Please Print Clearly Patient s First Name Middle last Current Height / Weight Mailing Address City State Zip Home Phone Work Phone Cell /Pager Email address Okay to contact you by email? Yes No / / Male Female Date of BirTH Social Security # race / Ethnicity Employer s Name Employment Status: Full Time Part Time Unemployed Retired Primary Care Physician referring Physician Insurance Information (please have your insurance card available for copying) Provider Name address Policy ID # Group # Subscriber s name / / Subscriber s D.O.B. I am interested in (please circle one): LapBand Gastric Bypass Sleeve Gastrectomy Unsure Previous Bariatric Surgery? Yes No Have you ever been to see us before for a consultation? Yes No How did you hear about us? Did you attend an informational session? Yes No When? Do you have 6 months of diet history? Yes No

Bariatric Patient Registration Page 2 of 7 Patient History Form Knowing your detailed medical history information is very important for our assessment of your health. Obesity and its associated diseases and risk factors increase mortality and surgical complications. We rely on the information you provide, therefore it is imperative for safety and insurance purposes that a detailed medical history be performed. i am also aware of the following: No tobacco products are permitted for 8 weeks before surgery. This gives your lungs a chance to better provide oxygen to your blood, which can help decrease the risk of infection, pneumonia, and especially improve wound healing. Second hand smoke is also irritating to the lungs. We will not operate on any patient that is an active smoker and may require you to take a laboratory test that confirms you are smoke free. Primary Care Physician Address Phone Fax Specialist Physician(s) (pulmonologist, gastroenterologist, endocrinologist) Your Weight Loss History Most insurance companies require documented evidence of previous weight loss attempts so it is critical that you fill this out in detail. Please include dates as well as length oftime ofeach diet, to the best ofyour knowledge. Have you completed a recent diet for this visit? Yes No What was your best weight loss with dieting? Supervised Attempts (e.g. Weight Watchers, OptiFast, New Directions, etc.)

Medication Prescribed For Weight Loss Bariatric Patient Registration Page 3 of 7 Medications may be listed as both as generic and name brand. Check the one prescribed to you and the length of time you were on these medications. Phentrol Dexatrim Meridia Pondimin Acutrim Dexfenfluramine Obalan Redux Adipex-P Didrex Orlistat Tepanol Amphetamines Fastin Phendiet Xenical Anorex Fenfluramine Phentermine Benzphetamine Ionamin Piegine Review of Medical Problems (please check and/or explain any of the items listed) Cardiovascular Heart problems: Chest pains: Previous heart attack: High blood pressure: Previous blood clot or pulmonary embolism: Shortness of breath: Shortness of breath while exercising: High cholesterol: High triglycerides: Feel tired all the time: diabetes and Endocrine System diabetes Mellitus: Type I Type 2 When was your diabetes first diagnosed? How long have you been taking oral agents? How long have you been taking insulin? Pre-diabetic (Abnormal glucose tolerance test): Gestational diabetes: age at diagnosis Hypoglycemia: Thyroid problems (requiring medication): gastrointestinal Gallbladder problems Do you have gallstones diagnosed by ultrasound? Yes No Surgery to remove gallbladder: By open incision Laparoscopically

Bariatric Patient Registration Page 4 of 7 gastrointestinal, cont. Stomach ulcers: Heartburn: How often do you have heartburn and do you take medications for it? respiratory Asthma: Last attack? COPD: Bronchitis: Is it recurring? Yes No Number of times in past 2 years: Pneumonia: Blood clots in lungs: Blood clots in legs: Smoking History: Starting age How many packs per day? When did you stop? Previous Sleep Study: Do you have one scheduled? Yes No Currently use or have previously been prescribed a CPAP or BiPAP machine: musculoskeletal Joint Pain Back Pain Neck Pain Arthritis Currently taking anti-inflammatory or pain medicine: Swelling in your legs: Swelling in your feet: Varicose veins: Ulcers of the leg: kidney & Bladder Renal insufficiency or failure Kidney stones

Bariatric Patient Registration Page 5 of 7 blood History of bleeding problems Low platelet count Previous blood transfusion Neuro-psychotic Depression/Anxiety: Caused by obesity? Yes No Requiring medication? Seizures Requiring medication? Severe headaches Requiring medication? Visual problems Been in counseling History of alcohol abuse: How long have you been sober? History of drug abuse: How long have you been clean? Eating disorder: Bulimia: Anorexia Nervosa: Allergies Medication allergy/ies: Associated reaction: Food allergy/ies: Associated reaction: Allergic reaction to anesthesia Family member has had an allergic reaction to anesthesia Allergy to Latex products past Surgical History (Please provide a complete history of all your previous surgeries, using the list of surgical procedures below) Tonsillectomy Cholecystectomy (gallbladder removal) Appendectomy Hysterectomy (removal of uterus) Cesarean Section (C-section) Oophorectomy (removal of ovary) Hiatal Hernia surgery Cardiac Surgery Previous Bariatric Surgery: if yes, with whom? Where performed? When? Highest weight lowest weight Others:

Bariatric Patient Registration Page 6 of 7 For Women Previous diagnosis of Polycystic Ovarian Syndrome (PCOS): Problems conceiving: How many pregnancies have you had? How many children do you have? Experience pain with your period: Medications (Report name, dose, and frequency and what you are taking it for) Medication dosage Frequency Condition Family Medical History Mother Father Sibling aunt uncle Grandparent Obesity Diabetes Heart disease High blood pressure Cancer Arthritis Early Death Has any member of your family suffered from Blood Clots or Pulmonary Embolism? Yes No If yes, please describe:

Bariatric Patient Registration Page 7 of 7 Patient Statement I am aware that Bariatric surgery is not a quick fix but rather a tool for controlling weight, combined with exercise and proper nutrition. I am aware that I will be expected to follow up post op on a regular basis, and be required to take vitamins, and supplements for the rest of my life. I am also aware that reversal of this surgery is not recommended. The information on my medical history form is true and correct to the best of my belief. Patient s signature Patient s Name Today s Date

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