Patient Intake Questionnaire
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- Brittney Ray
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1 Patient Intake Questionnaire Name: Date of Birth: Date: Primary Phone Number: Please enter the information below to begin the registration process: Please provide information about your dieting history. This information is crucial to obtaining insurance coverage. Please provide as much detail as possible. Appetite suppressant Atkins Cabbage Diet Curves Diet Pills Dr. Slott Exercise Program HCG Jenny Craig Joined a Gym/Health Club Juice Diet LA Weight Loss Low Calorie Low Carb Low Fat Metabolic Weight Loss MUSC First Step Nutrisystem Paleo Personal Trainer/Gym Phenteramine Physicians Weight Loss Real Life Slim Fast South Beach Diet Weight Watchers Worked with a Dietitian Other: For the following questions, please check the correct answer or circle yes/no depending on the option given. Endocrine/Metabolism Diabetes Mellitus No symptoms or evidence of diabetes early diabetes Diabetes, controlled with oral medication Diabetes, controlled with insulin and oral medication Diabetes, controlled with insulin Diabetes with severe complications Have you ever been diagnosed with thyroid disorder? Y N Do you have high cholesterol? No cholesterol problems High cholesterol, no treatment required High cholesterol, controlled with diet change High cholesterol, controlled with single medication High cholesterol, controlled with multiple medications Poorly controlled cholesterol High triglycerides (fats)? 1
2 Gout No gout High blood uric acid levels, no symptoms High blood uric acid levels, taking medication Painful joints as a result of gout Damaged joints as a result of gout Unable to walk or disabled as a result of gout General Health Status Functional Health Status Independent Partially Dependent Totally Dependent Unknown Difficulty Walking Able to perform daily activities Able to walk 200 ft with assistance device (cane or crutch) Cannot walk 200 ft with assistance device (cane or crutch) Requires wheelchair Pulmonary Are you oxygen dependent? Y N Do you have a history of severe COPD? Y N Do you have a history of pulmonary embolism? Y N Asthma No symptoms Intermittent mild symptoms, no medication Symptoms controlled with oral inhaler Well controlled with ongoing daily medications Symptoms not well controlled, requires oral steroids Hospitalized within last two years, history of intubation Obstructive Sleep Apnea No symptoms or evidence of sleep apnea Symptoms of sleep apnea Sleep apnea not requiring CPAP or BiPAP Sleep apnea requiring CPAP or BiPAP Sleep apnea requiring oxygen treatments Sleep apnea with complications (heart failure, etc.) Gastrointestinal Do you have heartburn or esophageal reflux that requires medication? No history of reflux or heartburn Occasional symptoms, not using mediations Use medications intermittent Uses prescribed acid blocking medications Use double the normal recommended dose of acid blocking medications Have had prior surgery for severe reflux 2
3 Do you suffer from ulcers in your stomach or intestines? Y N Have you had any blood per rectum recently? Y N Gallstones or gallbladder disease? No history of gallstones Gallstones with no symptoms Gallstones with intermittent symptoms Had gallbladder removed or have severe symptoms from gallstones Suffered complications as a result of gallstones (pancreatitis, sever bile duct infections) Had gallbladder removed but continue to have ongoing problems Fatty Liver Disease No history of liver disease Enlarged liver, normal liver blood tests Enlarged liver, abnormal liver blood tests Enlarged liver, cirrhosis Liver failure Need or have had a liver transplant Have you ever vomited blood? Y N Abdominal Hernia No hernia Asymptomatic hernia, no prior operation Symptomatic hernia Successful repair Recurrent hernia or extremely large hernia Large hernia with complications or multiple failed hernia repairs Do you have Crohn's disease? Y N Have you ever been diagnoses with irritable bowel syndrome? Y N Musculoskeletal Arthritis (degenerative joint disease) No symptoms of joint disease related to weight Pain with walking Require anti-inflammatory medications Pain with walking around house Surgical intervention required (arthroscopy) Awaiting or past joint replacement or other disability Do you suffer from arthritis in your hips? Y N Do you suffer from arthritis in your knees? Y N Do you have rheumatoid arthritis? Y N Have you ever been treated with steroids for your arthritis? Y N 3
4 Do you suffer from back pain? No symptoms of back pain Intermittent symptoms not requiring medical treatment Symptoms requiring non-narcotic treatment Degenerative changes, symptoms requiring narcotic treatment Surgical intervention done or recommended pending weight loss Failed previous surgical intervention with existing symptoms Fibromyalgia No history of fibromyalgia Treatment with exercise Treatment with non-narcotic medications Treatment with narcotics Surgical intervention done or recommended pending weight loss Disabling, treatment not effective Cardiovascular Have you been diagnosed with high blood pressure? No high blood pressure Been diagnosed with high blood pressure but never prescribed medication Been diagnosed in the past, but not currently on medication for high blood pressure High blood pressure, treated with one medication High blood pressure, treated with multiple medications Poorly controlled high blood pressure with kidney failure or eye disease Do you have difficulty sleeping or breathing while laying flat on your back? Y N Lower Extremity Swelling No symptoms of leg swelling Occasional leg swelling, not requiring treatment Symptoms requiring the use of water pills, leg elevation or pressure stockings Ankle/shin skin breakdown (venous stasis ulcers) Disability, decreased function, hospitalization Do you have venous stasis disease? Y N DVT or Pulmonary Embolism No history History of blood clot in legs treated with blood thinners Recurrent lower extremity blood clots requiring lifelong blood thinners History of pulmonary embolus (blood clots traveling to the lungs) Recurrent history of pulmonary emboli, decreased lung function, requiring hospitalization Vena cava filter previously placed Ischemic Heart Disease No history or symptoms of ischemic heart disease Abnormal EKG, no other heart problems History of heart attack or taking Nitro I have had an angioplasty or heart bypass I am currently having chest pain 4
5 Do you suffer from congestive heart failure? No symptoms of congestive heart failure Symptoms of congestive heart failure with strenuous activity Symptoms of congestive heart failure with ordinary activity Symptoms of congestive heart failure with minimal activity Symptoms of congestive heart failure at rest History of chest pain? No chest pain symptoms or angina Chest pain with extreme exertion Chest pain with moderate exertion Chest pain with minimal exertion Chest pain at rest History of heart attack Do you have a pacemaker or defibrillator? Y N Have you had a cardiac stent or balloon angioplasty? Y N Do you have sickle cell? No Sickle cell disease Sickle cell trait Renal Have you been diagnosed with renal insufficiency? Y N Are you currently requiring or on dialysis? Y N Stress urinary incontinence? Y N Nutritional/Immune/Oncology/Other Do you have Hepatitis A? Y N Do you have Hepatitis B? Y N Do you have Hepatitis C? Y N Do you have HIV/AIDS? Y N Have you ever been diagnosed with Cancer? Y N Have you ever had to use Steroids/Immunosuppressants for a chronic condition? Y N Have you ever had to use therapeutic anticoagulation? Y N Do you have PCOS? Y N Do you have multiple sclerosis Y N 5
6 Social History Please select the answer that best describes you Tobacco: Never Smokes Non-smoker, quit less than 1 year ago Non-smoker, quit less than 5 years ago Non-smoker, quit less than 15 years ago Non-smoker, quit in distant past Smokes a few cigarettes per week Alcohol Consumption: Never Rarely (1-2 drinks per month) Social (1-2 drinks per week) Smokes ½ pack per day Smokes 1 pack per day Smokes 1 ½ pack per day Smokes 2 packs per day Smokes >2 packs per day Frequent (1-2 drinks per day) Heavy (2 or more drinks per day) History of alcoholism, currently not drinking Drug Use: None Occasional use of recreational drugs (marijuana, cocaine) Intravenous drug use History of intravenous drug use PREOPERATIVE QUESTIONS How long have you thought about surgical options for your weight loss? How long have you struggled with obesity? What is your highest weight? Has anyone in your family had bariatric surgery? No Yes, sibling Yes, spouse Yes, parent Which surgical procedure are you interested in (please circle): RNY Gastric Bypass Revision Adjustable Gastric Band Undecided Sleeve Gastrectomy How did you hear about our program? Co-worker Physician Internet Friend Radio Newspaper Yes, child Yes, other relative Family Television Brochure Name of referring physician: Primary Care Physician Information: Name, address, phone and fax number Are you a Jehovah s Witness? Yes No 6
7 Please list all the medications you are currently taking and the dosage: 1. Dose: 2. Dose: 3. Dose: 4. Dose: 5. Dose: 6. Dose: 7. Dose: 8. Dose: 9. Dose: 10. Dose: Do you have any drug allergies? Yes: No, I have no known drug allergies PREVIOUS SURGICAL PROCEDURES: Please check all that apply & list date of surgery Appendectomy open Appendectomy Lap Bariatric Surgery Adjustable Gastric Band Bariatric Surgery Sleeve Bariatric Surgery Roux-en-Y Gastric Bypass Bariatric Surgery Loop Gastric Bypass Bladder Sling Breast Augmuntation Breast Reduction C-Section Carpal Tunnel Choleycystectomy (gallbladder removal) open Choleycystectomy (gallbladder removal) laparoscopic D&C Hysterectomy open Hysterectomy vaginal Inguinal Hernia Repair Incisional Hernia Repair Kidney Stone Removal Lasik Eye Surgery Partial Colectomy Tonsillectomy Tubal Ligation Umbilical Hernia Repair None Other: 7
8 Family History Mother Weight: Conditions: Deceased? No Yes, at age: Father Weight: Conditions: Deceased? No Yes, at age: Are there any other family members with relevant history? No Yes Please list: Employment Status: Full-time Part-time Self employed Homemaker Student Retired Disabled Unemployed Employer: Pharmacy Name & Address: I agree that the information given on this questionnaire is true based on my current knowledge. Signature Date 8
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