Rex Bariatric Specialist
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- Loren Shepherd
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1 Rex Bariatric Specialist NUTRITIONAL AND DIET EVALUATION A. Weight/Dieting History: 1. List your approximate weight in pounds at the following ages? 10 y/o lbs, 20 y lbs, 30 y lbs, 40 y lbs, 50 y lbs, 60 lbs 2. Please list your heaviest weight, (exclude pregnancies) lbs age. 3. Have you tried weight loss through structured dieting or other treatment? Yes No 4. If yes, list all food/ liquid diets or treatments attempted. Many insurance carriers require this information; therefore, please provide an accurate and complete listing. Diets: Behavioral Treatments: Atkins/Low Nutri-system TOPS Diet Counseling Carb Grapefruit Optifast/Medifast Weight Watchers Hypnosis Jenny Physicians Weight Loss Volumetrics Personal physician Craig Liquid Slimfast Zone Diet Residential Diet Center Protein Metabolife South Beach Diet Exercise Trainer Name of Diet/Treatment Lbs. Lost Physician directed? 5. List all medications used by you for weight loss. Listed below are the most common medications. Please provide an accurate and complete list of any medications used in the past: Acutrim, Alli, Bontril, Didrex, Phentermine, Xenical, Dexatrim, Fen/Phen, Meridia, Redux. Medication & Dose Start year Length (Mos.) Lbs. Lost Physician directed Rex Bariatric Specialists, 2800 Blue Ridge Road, Suite 300, Raleigh, NC P: F:
2 NUTRITIONAL PRE-SCREENING ASSESSMENT B. Diet Behavior 1. Current challenges to improving my health include: a. Lack of time d. Family responsibility b. Lack of motivation e. Illness or physical limitation c. Work Schedule f. Other d. Too expensive Social Calendar 2. My hidden sources of extra calories most likely come from: a. Large portions h. Going out to eat b. Soda/other beverages i. Eating while watching television c. Sweets j. None identified d. Chips k. Other: e. Fried foods f. Eating when bored/upset/stressed (not hungry) g. Eating while cooking 3. How do you feel about making behavioral changes? a. Ready to start making changes now b. Ready to think about making changes c. Not ready to make any changes to my current lifestyle 4. How many days a week do you eat breakfast? a. 1 day b. 2-3 days c. 3-5 days d. 5-7 days 5. How often do you eat between meals? a. Seldom b. 1 time per day c. 2 time per day 6. What is your usual pattern for the evening meal? a. Seldom eat dinner b. Lightest meal c. Moderate meal d. Largest meal 7. Which sources of protein do you eat most often? a. Red meat b. Fish and Chicken c. Eggs and Dairy d. Tofu, beans, and lentils 8. I eat appropriate portion sizes: a. I don t know b. Rarely c. Sometimes d. Often 9. I eat fruits and vegetables. a. No, I do not. b. With cheese, butter, or dressing c. Canned d. Fresh or frozen Rex Bariatric Specialist 2800 Blue Ridge Road, Suite 300 Raleigh, NC C: F:
3 NUTRITIONAL PRE-SCREENING ASSESSMENT 10. Which types of carbohydrates do you choose most often: a. I avoid carbs b. Whole grains c. White/refined carbs d. Sweets 11. How often do you eat low-fat dairy products? a. Seldom b. 1-2 times per week c. 1 time per day d. 2 times per day 12. Which types of drinks do you choose most often? a. Water b. Flavored water and diet soda c. Fruit juice d. Sweet tea or regular soda 13. How much alcohol do you consume? a. 1-2 times per week b. 1 time per day c. 2 or more time per day d. None 14. Does your work or daily activity primarily include the following: a. Sitting b. Standing c. Walking or moderate lifting d. Heavy manual labor 15. How often do you exercise for 20 minutes or more each week? a. Seldom b. 1-2 times per week c. 3-4 times per week d. Daily 16. How many hours of sleep do you typically get a night? a. 1-2 hours b. 3-4 hours c. 5-6 hours d. 7 or more hours. Rex Bariatric Specialist 2800 Blue Ridge Road, Suite 300 Raleigh, NC C: F:
4 REX BARIATRIC SPECIALISTS Referring Physician: NAME Chart# DOB Social History/ Demographics Race African American Asian Caucasian Hispanic Native American Other Pacific Islander/Hawaiian Gender Male Female Employ Full Time Part Time Self Employed Homemaker Student Retired Disabled Unemployed Not Specified Marital Single Married Divorced Other Insured Private Insurance Medicare Medicaid Other Government Insurance Self Pay Past Surgical History Previous Bariatric Surgery Year/Original Weight/Lowest Weight Achieved/Surgeon/Complications Other Surgery Past Medical History Please check all medical problems you have had in the past: NONE Cardiovascular High Blood Pressure Congestive Heart Failure Ischemic Heart Disease Angina Peripheral Vascular Disease Lower Extremity Edema DVT/PE (Clots) Atrial Fibrillation Metabolic Diabetes (Glucose Metabolism) Lipids/ Hyperlipidemia Gout/ Hyperuricemia Pulmonary Obstructive Sleep Apnea Obesity/Hyperventilation Pulmonary Hypertension Asthma COPD Gastrointestinal GERD (reflux) Cholelithiasis (gallbladder) Liver Disease Diverticulitis Pancreatitis Inflammatory Bowel Gastric ulcer Musculoskeletal Back Pain Musculoskeletal (Joint) Fibromyalgia Reproductive Polycystic Ovary Disease Menstrual Irregularity Infertility Psychosocial Mental Health Diagnosis Depression Psychosocial Impairment Alcohol Use Substance Abuse Tobacco Use General Stress Incontinence (urine) Pseudotumor Cerebri Abdominal Hernia Functional Impairment Abdominal Skin/Pannus Endocrine: Hyperthyroid Adrenal disorder Renal: Renal Failure Kidney Stones Neurologic Stroke or TIA Muscle Weakness Alzheimer s Immunity HIV/AIDS Bleeding Disorder Clotting Disorder Lupus Autoimmune Disease Cancer (list type) Family Medical History Relationship Diabetes Hypertension Breast Cancer Colon Cancer Heart Disease Other: Rex Bariatric Specialist 2800 Blue Ridge Road, Suite 300 Raleigh, NC Tel Fax (pg.1)
5 Rex Bariatric Specialist NAME Chart # Date of Birth Please List Any Allergies and Reaction: Latex Allergy Medications: Please list all prescription and over the counter medications you are taking: Pharmacy Name Phone Number Name Dose Prescribed for: Name Dose Prescribed for: Are You Currently Experiencing any of the Following Symptoms? Constitutional Y/ N Palpitations Genitourinary Neurological Y/ N Weight gain Y/ N Calf or foot pain Y/ N Painful Urination Y/ N Numbness Y/ N Fever Y/ N Lower leg swelling Y/ N Bloody Urine Y/ N Confusion Y/ N Night sweats Respiratory Musculoskeletal Y/ N Convulsions Y/ N Chills Y/ N Shortness of breath Y/ N Joint Pain Y/ N Tingling hands/feet Y/ N Loss of appetite Y/ N Wheezing Y/ N Joint Swelling Y/ N Restless legs Y/ N Fatigue Y/ N Chronic Cough Y/ N Joint Stiffness Y/ N Limb Weakness Eyes Y/ N Coughing Blood Y/ N Limb Pain Y/ N Difficulty Walking Y/ N Visual impairment Gastrointestinal Integumentary Psychological Y/ N Blind spot Y/ N Abdominal Pain Y/ N Skin Lesion Y/ N Addiction ENT Y/ N Nausea Y/ N Skin Wound Y/ N Anxiety Y/ N Trouble Swallowing Y/ N Vomiting Y/ N Jaundice (Yellow Skin) Endocrine Y/ N Hearing loss Y/ N Heartburn Y/ N Infections Y/ N Hot Flashes Y/ N Hoarseness Y/ N Constipation Y/ N Rash Y/ N Muscle Weakness Y/ N Snoring Y/ N Diarrhea Breast Y/ N Deepening of voice Cardiovascular Y/ N Change in Stools Y/ N Breast Tenderness Heme/Lymph Y/ N Rapid Heart Rate Y/ N Black/Tarry Stools Y/ N Breast Discharge Y/ N Easy Bleeding Y/ N Chest Pain at Rest Y/ N Rectal Bleeding Y/ N Palpable Breast lump Y/ N Bruising Y/ N Chest Pain w/ activity Y/ N Hemorrhoids Y/ N Ski Changes Y/ N Swollen Glands Other I Certify the above to be accurate Date: Time: Review by: Date: Time: Rex Bariatric Specialist 2800 Blue Ridge Road, Suite 300, Raleigh, NC Tel: (919) Fax: (919) (pg. 2)
6 UNDERSTANDING YOUR HEALTH INSURANCE/ WEIGHT LOSS SURGERY BENEFITS Weight loss surgery (Gastric bypass, Sleeve Gastrectomy, and Lap Band) is an elective surgical procedure and not all insurance plans include coverage. To understand your insurance coverage, use the following worksheet to guide you through the inquiry process and help accurately determine your current insurance plan. Please use the questions as listed below when speaking with your insurance carrier. This language allows your carrier representative to best understand your question and explain the details of your benefits. We also ask that you attach a copy of your insurance card (both front and back) to your packet. We contact your carrier separately to confirm your benefit coverage for weight loss surgery. Phone Tips: Some patients encounter customer service representatives who misinterpret your call as an attempt to obtain authorization for your surgery. Please make clear to the customer service representative that you are calling for explanation and clarification of your plan benefits, and not asking to be pre-certified or pre-authorized for bariatric or weight loss surgery. If you still feel unclear about your benefits after speaking to a representative, politely ask to speak to the supervisor. What if Morbid Obesity Related Surgery is listed as an exclusion in your insurance plan? From the standpoint of both your insurance carrier and employer, surgical coverage often differs between obesity surgery and other surgery, such as coronary artery bypass, fracture repair, appendectomy, or a mastectomy. Specifically, some insurance contracts list obesity surgical options as plan exclusions (i.e. not covered). Insurance exclusions, however, do not indicate the medically necessity of obesity surgery. Instead, the exclusion simply means that your employer elected against including this service as a covered benefit in your plan. This is similar to other exclusions for cosmetic surgery, infertility services, and Lasik vision correction. If you encounter a morbid obesity exclusion in your plan, meet with your Human Resources Department to discuss the possibility of changing your plan benefits. You might also explore appealing for special consideration on an individual case basis through your employer and insurance company. HEALTH INSURANCE INFORMATION QUESTIONAIRE Please complete each question as thoroughly as possible. Insurance Company Name: Member Customer Service Phone #: Date Contacted: Person spoken to: 1. Hello, my name is, and I would like to learn about my plan benefits with regard to morbid obesity surgery, such as gastric bypass and lap banding. Does my policy cover services related to morbid obesity or is it an exclusion of my contract? Coverage Exclusion If it s an exclusion, the rest of the questions will not be applicable. 2. Is a referral necessary to be seen by a Bariatric Surgeon? Yes No Rex Bariatric Specialist 2800 Blue Ridge Road, Suite 300 Raleigh, NC C: F:
7 2. Does my policy cover services for any related surgery clearances such as cardiac, pulmonary, nutritional, and psychological evaluations and Pre-Admission Testing? Yes No 3. If benefits are allowed, what are the Medical Policy requirements? How can I obtain a copy of them for review? (Is it available on internet or can one be mailed to me?) Is Center of Excellence (COE) required? Yes No BMI minimum: Diet history: months within the past months. Exercise history: months within the past months. Weight history: years overweight (Do not confuse with a diet history) Does my policy cover services for dietary/nutritional consults? Any additional requirements: Yes No (If yes, explain on separately attached form.) 5. At what level does my policy pay for the following services (i.e.; 100%, 80%)? % of Payment CPT CODE DIAGNOSIS CODE Office Consultation Gastric Bypass Open Gastric Bypass Laparoscopy Laparoscopy, gastric band Do I have a deductible that must be satisfied? If so, how much? $ 7. What is my office visit co-pay amount? 8. Following surgery, periodic office visits are required after the 90 day global period and at minimum annually. Are these office visits a covered benefit? Will they be covered when I am no longer diagnosed as morbidly obese? Yes No 9. I will also need periodic lab work done following my surgery, and at minimum, at least annually. Will these services by covered? Will they be covered when I am no longer diagnosed as morbidly obese? Yes No 9. Attach a copy of your insurance card (front and back) to this form: Patient Name (printed) Social Security Number Patient Signature Date Return completed form to: Rex Bariatric Specialist Krista Herrell, Bariatric Navigator 2800 Blue Ridge Road Raleigh, NC Phone: Fax: Rex Bariatric Specialist 2800 Blue Ridge Road, Suite 300 Raleigh, NC C: F:
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