Name Today s Date Age Date of Birth Phone Address How did you find us? Emergency Contact Name Relationship Phone Home ( ) Work ( ) Cell ( ) Address Physicians Primary Care Cardiologist Psychologist Sleep Doctor Pulmonologist (Lung) Endocrinologist Pain Doctor Orthopedic Surgeon Dietician 1 of 10
Your Insurance company Policy # Group # Phone # Secondary Insurance company Policy # Group # Phone # Does your insurance cover bariatric surgery? Do you know what operation you are interested in? Gastric Bypass Gastric Sleeve Gastric Band Revision Other I don t know! Have you attended our bariatric seminar? When Please note that you must turn this form in to the surgeon of your choice once you have completed it. Dr. Thuy Hughes St. Charles Medical Group Dr. Stephen Archer BMC Bariatrics 1245 NW 4th St., Suite 101 1501 NE Medical Center Dr Redmond, OR 97756 Bend, OR 97701 541.548.7761 FAX 541-598-3485 541.706.6518 FAX 541.317.4537 2 of 10
Nutrition History Current Height Weight Maximum Height Weight Age Minimum Height Weight Age Previous Weight Loss Efforts (self directed, fad, medications, group) Diet Medication Other Year Weight Loss Weight Regained List any previous weight loss operations, the surgeon, the hospital 3 of 10
Food Allergies Yes No List and reaction Estimate how many ounces of each of these you drink daily: Water Soda Coffee Sweet tea or other sugar sweetened beverages Energy drinks Milk Juice Diet drinks What one food habit would you like to let go of? What is one thing you hope to do again? What foods do you crave? Any specific time of day? Check the types of meals in a typical week for you and your family How Often? Home-cooked Heat and Serve Fast Food Other Restaurants Do you identify with the term food addiction? What foods do you feel addicted to? Who does the grocery shopping? 4 of 10
Which of the following are true for you? Lack of appetite in the morning Eat over half your calories after dinner Wake up and binge eat or binge to sleep Uncontrollable desire to eat at night? Yes No Eat large amounts of food in one sitting Continue to eat when not hungry Eating feels out of control Eat rapidly during binge episodes Eat or snack all day long Feel ashamed, guilty, disgusted after eating Eat in secret Eat before/after eating with others Yes No Eat more with negative feelings Eat more with positive feelings Eat more after difficult day at work Eat more after difficult interactions 5 of 10
What led you to consider bariatric surgery and what are your expectations about bariatric surgery for you specifically? Total hours of exercise per week Access to exercise facilities Exercise preferences Barriers to exercise 6 of 10
Medications Name Dosage Frequency 7 of 10
Medical History Disease Year Diagnosed Other Details Diabetes Heart Disease/Heart Attack Insulin? Cardiac stents? High Blood Pressure Sleep Apnea CPAP? Heartburn or acid reflux Asthma/COPD Cancer Arthritis Urinary Incontinence Depression Elevated Cholesterol Blood Clots Latex Allergy Polycystic Ovarian Syndrome Gout Stroke or TIA Thyroid Problems Liver Problems/Hepatitis Venous Stasis/Varicose Veins Kidney Problems Prostate Problems Anesthesia Problems 8 of 10
Do you accept blood transfusions? Medication Allergies? List Please list previous operations (list abdominal operations first) Operation Year Surgeon Hospital Colonoscopy When Where Findings Upper Endoscopy or EGD When Where Findings Mammogram When Where Findings Pap Smear When Where Findings 9 of 10
Psychiatric History Diagnosis How Long Treatment Y/N Anxiety Depression Bipolar Panic Attacks Alcoholism Drug Addiction Schizophrenia Eating Disorder How much alcohol do you drink weekly? Do you use marijuana? How much? Do you use tobacco? What kind, how long? Who will be with you at the hospital? Who will be staying with you after surgery? What was the last year of school you attended? Current occupation? Present relationship status? Are you able to walk most of the time? 10 of 10