(Title) First Name MI Last Name Maiden Name Suffix. What do you prefer to be called?

516 South Division Street, Suite 105 Cedar Falls, IA 50613-2381 Tel 319.268.3990 Fax 319.268.3995 Patient Demographic Information: Date (Title) First Name MI Last Name Maiden Name Suffix What do you prefer to be called? Street Address (including apartment number) City State County Zip Code Date of Birth Age Gender... r Male r Female Social Security Number Home Phone Work Phone Cell Phone Number E-mail Address What phone number is best to reach you? Emergency Contact Information: Who could we contact in case of an emergency? Relationship 1st Phone Number r Home r Work r Other 2nd Phone Number r Home r Work r Other Insurance Information: Name of Your Primary Medical Insurance Carrier Group Number ID Number Name of the Insured Relationship to Insured... r Self r Spouse r Child r Other Address Telephone Number(s) Name of Your Secondary Medical Insurance Carrier Group Number ID Number Agreement Number Name of the Insured Relationship to Insured... r Self r Spouse r Child r Other Address Telephone Number(s) Page 1 of 9

Patient s Name: Patient s Doctor Information: (First and Last Name) Name of Primary Care Physician Please list any other doctors you see: Name of Doctor Speciality Name of Doctor Speciality Name of Doctor Speciality Pharmacy Information: Please provide the following information on the pharmacy you frequent the most. Name of Pharmacy How did you hear about Midwest Institute of Advanced Laparoscopic Surgery at Wheaton Franciscan Healthcare-Iowa? r Primary Care Provider: r Weight Management Center r Friend/Family r Internet r Television Special r Television Advertisement r Magazine/Newspaper Article r Other Provider Specialty r Other Weight/Diet History: 1. What is your current height? Feet Inches 2. What is your current weight? Pounds Page 2 of 9

Patient s Name: Allergy Information: 1. Do you have allergies to any medications / substances?... a. If yes, list Reaction b. If yes, list Reaction c. If yes, list Reaction d. If yes, list Reaction e. If yes, list Reaction 2. Do you have any environmental / food / latex allergies... a. If yes, list Reaction b. If yes, list Reaction c. If yes, list Reaction d. If yes, list Reaction e. If yes, list Reaction Medication Information: List any prescription or over-the-counter medication and natural/herbal/vitamin supplements you are currently using. Please copy the name straight from the bottle. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Times Years Started on Medications Dose per Day on Medication Purpose Please check here if you take more than 14 medications and then turn this page over and continue to list the rest of your medications. Page 3 of 9

Patient s Name: Previous Surgery Information: Please list any surgical procedure you have had, the reason and the year. If relevant, please specify if the surgery was performed laparoscopicly or open. r I have had no surgical procedure in the past. Laparoscopic Open Have you, or a blood relative, ever had any trouble with anesthesia?...r Yes If yes, please explain what occurred. Medical Health Information: Has a doctor or other health care provider told you that you have any of the following conditions? Please indicate by marking an X in the appropriate box. Specify the year diagnosed and the physician who currently manages the problem. Cardiac: (Heart) Coronary Artery Disease Heart Attack If yes, treatment Elevated Cholesterol Elevated Triglycerides Congestive Heart Failure Valvular Heart Disease (e.g. Mitral Valve Prolapse, Mitral Valve Regurgitation, etc.) Rheumatic Fever Heart Murmur Heart Arrhythmia If yes, describe condition (e.g. Irregular Heart Beat) Hypertension (High Blood Pressure) Heart Block Other Heart Disease If yes, describe condition Page 4 of 9

Pulmonary: (Lung) Have you ever required oxygen? Are you currently on oxygen? Asthma Pneumonia Chronic Bronchitis COPD (Emphysema) Tuberculosis Diagnosed Sleep Apnea Patient s Name: If yes, treatment If on CPAP / BiPAP, what are the settings Endocrine: Diabetes Mellitus Year Diagnosed Doctor If yes, do you currently treat with insulin?... Type: r 1 r 2 If you are a female: Polycystic Ovarian Year Diagnosed Doctor Disease (PCOS) If yes, treatment Neuropathy If yes, do you have any numbness/tingling/pain in your hands, legs and/or feet?... Retinopathy Have you been treated for any diabetic changes in your eyes?... If yes, explain Nephropathy Have you had any kidney problems related to your diabetes?... Hyperthyroid Hypothyroid Adrenal (Cushings) Other Gastrointestinal: Reflux Disease (Heartburn) Hiatal Hernia Peptic Ulcer Disease Gallbladder Disease Hepatitis Other Liver Disease Irritable Bowel Disease If yes, describe condition If yes, Type r A r B r C r Uncertain of Type Treatment If yes, describe condition Inflammatory Bowel Disease If yes, describe condition (Crohn s Disease, Ulcerative Colitis) Other Page 5 of 9

Patient s Name: Vascular Disease: Arterial Vascular Disease Pulmonary Embolism Deep Vein Thrombosis Superficial Phlebitis Peripheral Edema (swelling legs, ankles) If yes, do you currently treat with diuretics (water pills)?... Leg Ulcers If yes, do you currently have ulcers?... Varicose Veins Renal: Kidney Disease Urinary Stress Incontinence Kidney Stones If yes, treatment If yes, treatment Central Nervous System: Seizure Disorders CVA (Stroke) Migraine Headaches Other Orthopedic: Chronic Lower Back Pain Chronic Neck Pain Diagnosed Osteoarthritis/ r Yes r If yes, treatment No Year Diagnosed Doctor Degenerative Joint Disease If yes, joints involved r Neck r Shoulders r Back r Hips r Hands/Wrists r Knees r Ankles r Feet r Heels Do you have painful joints (without osteoarthritis/djd)?... If yes, which joints? r Neck r Shoulders r Back r Hips r Hands/Wrists r Knees r Ankles r Feet r Heels Autoimmune Disease Year Diagnosed Doctor (e.g. Lupus, Rheumatoid Arthritis, Connective Tissue, etc.) Gout r Yes r Fibromyalgia r Yes r Explain Further: No Year Diagnosed Doctor If yes, list joint involved Have you ever had any broken bones of the face?... r Yes r Have you ever had broken bones of the back/neck?... r Yes r No Year Diagnosed Doctor No No Describe: Describe: Page 6 of 9

Blood Disorders: Anemia Patient s Name: If yes, type, if known Do you have, or have you had, any abnormalities with bleeding or clotting?... If yes, explain Emotional Disorders: Depression Bipolar Affective Disorder Anxiety Schizophrenia Eating Disorders If yes, what type Other Smoking / Drug / Alcohol / Caffeine History: 1. Do you drink any beverages that contain caffeine on a regular basis?... 2. Do you currently use tobacco?... 3. Have you ever used tobacco?... 4. Do you currently drink alcohol?... 5. Have you ever had a problem with alcohol in the past?... 6. Have you ever used any illicit drugs on a regular basis? (e.g. Marijuana, Cocaine, Heroin, Amphetamines, etc.) Cancer: 1. Type/Organ(s) Affected: Treatment: Year Diagnosed Doctor 2. Type/Organ(s) Affected: Treatment: Year Diagnosed Doctor 3. Type/Organ(s) Affected: Treatment: Year Diagnosed Doctor Page 7 of 9

Patient s Name: The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not experienced some of these things recently, try to work out how they would have affected you. Use the following scale to chose the most appropriate number for each situation: 0 = Would Never Doze 1 = Slight Chance of Dozing 2 = Moderate Chance of Dozing 3 = High Chance of Dozing Situation Chance of Dozing 1. Sitting and Reading... 2. Watching TV... 3. Sitting, inactive in a public place (e.g. theater or a meeting)... 4. As a passenger in a car for an hour without a break... 5. Lying down to rest in the afternoon when circumstances permit... 6. Sitting and talking to someone... 7. Sitting quietly after lunch without alcohol... 8. In a car, while stopped for a few minutes in the traffic... For Office Use Only Please indicate if any of the following conditions have ever been a significant problem for you by marking the appropriate box. Observed Sleep Apnea (stop breathing while sleeping)...r Yes Loud Snoring...r Yes Gasping for Breath at Night...r Yes Waking Up with Headaches (regularly)...r Yes Family History of Sleep Apnea...r Yes Which Family Member? (please check all that apply): r Father r Paternal Grandmother r Paternal Grandfather r Siblings r Mother r Maternal Grandmother r Maternal Grandfather Page 8 of 9

Patient s Name: Family History: In this section, complete this chart to the best of your knowledge. If you are adopted and/or have no knowledge of your biological family history, place an X below. r I have no knowledge of my biological family history r Adopted Family Member Present Medical Problems Deceased Age Age at Death Cause of Death Arthritis Cancer Deep Vein Thrombosis (DVT) Depression Diabetes - Type I Diabetes - Type II Heart Disease Hypertension Hyperthyroidism Mental Illness Obesity Sleep Apnea Stomach Cancer Mother Father Paternal Grandmother Paternal Grandfather Maternal Grandmother Maternal Grandfather Brother(s) Sister(s) Half Brother Half Sister 463051 8/1/14 tm Page 9 of 9