*3451 BARIATRIC SERVICE HEALTH QUESTIONNAIRE

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1 BARIATRIC SERVICE HEALTH QUESTIONNAIRE Name: Male Female Address: City: State: Zip: Home Phone: ( ) Mobile Phone: ( ) Primary Language: Religious Preference : Education Level: Date of Birth: Social Security #: Driver s license #: Marital Status: Married Single Divorced Separated Significant Other/ Partner Number of Dependents: Occupation: Employer: Employer Address: City: State: Zip: Phone: Ext.: Referring Physician: Phone: Emergency Contact Relationship: Spouse Partner Parent Friend Other Name: Phone: ( ) Address: City: State: Zip: Primary Care Physician Name: Address: City: State: Zip: Phone: Fax: Please list all physicians who are caring for you: First Name, Last Name Address/City/State/Zip Telephone Internist Psychologist Psychiatrist Gynecologist Cardiologist Pulmonologist Other Weight History: Please check the appropriate boxes and add notes as needed (please be specific). My obesity started: In childhood At puberty After a traumatic event After pregnancy In Adulthood Other Page 1 of 6 Revised October 2012

2 History of Weight loss attempts including Weight Loss Programs/Diets/Medications: Medically supervised weight loss programs (Please include dates & duration of program, and maximum weight loss) Weight loss programs (Please include dates & duration of program, and maximum weight loss) Diets (Please include dates & duration of diet, and maximum weight loss) Most weight lost with any attempt: Current Weight: Program: Height: Recent weight change in past 6 months: lbs. gain/loss (circle) Lowest weight past 5 years Highest weight past 5 years Additional notes regarding the onset of obesity: Taste preferences (please check all that apply): Sweets Salty Fast food Comfort foods Other Eating Habits (please check all that apply): Binge eater Stress Boredom Loneliness Other Food Preferences: Indicate which foods you prefer. In words, which food would most likely make you go off a diet? Rank each food from 1 You like very much to 4 You don t care Candy Ice cream Cookies Cake/pie Pizza Potatoes French Fries Pasta Chocolate Fast foods Chips Sodas Fried Foods Steak BBQ Snack Foods Fancy coffee drinks (mochas, frappuccinos, cappuccinos, lattes) Are there any food preferences? (re: religious or cultural) Please list any allergies: Medication allergies Reaction Other allergies Reaction Are you allergic to Latex? No Yes Reaction: Page 2 of 6 Revised October 2012

3 Please list any medications, vitamins/minerals and/or herbal supplements you are presently taking: Medication name (including if immediate or extended release, ex. XR, CR, IR, etc.) Dosage/Frequency Reason You Use Medication Past Surgical History: Please list all previous surgeries and hospitalizations: Procedure/Diagnosis: Date Hospital Obesity related conditions (please check if you have any of the following conditions): Belching of sour fluid Coughing or choking at night Daytime falling asleep Diabetes Mellitus Gout Heartburn/esophagitis/GERD High Cholesterol/Triglycerides Joint pain/arthritis Shortness of breath Sleep Apnea Syndrome Other Excessive vomiting Daily Headaches Depression/anxiety Gallbladder disease Abdominal Hernia Hiatal Hernia High Blood Pressure Leakage of Urine Rash/Dermatitis Swollen Ankles/Feet Page 3 of 6

4 Social History: How do you learn best? Hearing Watching Reading Doing Other Do you have any problems reading? No Yes Do you have any problems communicating? No Yes Do you need a translator or any special assistance during consultations? No Yes If Yes, please explain Do you have any problems making decisions, remembering, or thinking clearly? No Yes If Yes, please explain Do you have any values, beliefs or religious practices that may influence your treatment/care? No Yes If Yes, please explain Have you ever been physically, sexually, or emotionally abused? No Yes Would you like to receive information on abuse resources? No Yes Are you a smoker? No Yes Packs/day: How long have you smoked? Have you ever been a smoker? No Yes Age started: Age quit: Do you consume alcohol? No Yes Drinks/day: How many years have you used alcohol? Do you use recreational drugs? No Yes If yes, what drugs do you use, how often, and how many years? Exercise: Please describe your exercise routine. Include type of exercise, frequency and physical limitations. Past Medical History: Have You had any of the following medical conditions at any time: Condition No Yes Provider s Comments (Do not write in this column) Anemia Asthma Blood clot in legs Blood clot in lungs Blood transfusions Cancer Colitis (Ulcerative or Crohn s) Irritable Bowel Syndrome COPD (Chronic Lung disease) Epilepsy/Seizures Excessive/heavy bleeding Fainting Heart attack Heart failure Heavy drinking Hepatitis Kidney failure Liver disease Page 4 of 6

5 Condition No Yes Provider s Comments (Do not write in this column) Pneumonia Rheumatic fever Stroke Thyroid trouble Tuberculosis Ulcers Review of Systems: Please check all symptoms you have or have had. Write any additional symptoms/conditions. Constitutional, General Fever Fatigue Appetite changes Head, Eye, Ear, Nose, and Throat vertigo headache sinus problems loss of hearing blindness drainage from ear sore throat ear ache stuffy nose double vision hoarseness glaucoma hay fever ringing of the ears dizziness runny nose blurry vision glasses contacts hearing aid(s) L / R Pulmonary, Breathing persistent cough shortness of breath wake up at night short of breath Sleep apnea asthma chronic bronchitis wake up at night coughing or choking Use of CPAP/BiPAP/Home oxygen wheezing emphysema need to sleep sitting up Cardiovascular chest pain palpitations ankle swelling/ edema heart murmur heart attack High cholesterol/trigylcerides pain in legs high blood pressure poor circulation History of cardiac surgery Gastrointestinal abdominal pain gas/ flatus/ belching ulcers Irritable Bowel Syndrome rectal pain hemorrhoids vomiting constipation difficulty swallowing Crohn s disease rectal bleeding heartburn/reflux diarrhea painful swallowing Ulcerative colitis jaundice nausea bloating food gets stuck Genitourinary kidney stones pain with urination blood in urine frequent urination kidney infections leakage of urine Endocrine Women only Date of last menstrual period: irregular periods painful intercourse vaginal discharge vaginal bleeding Are you using birth control? No Yes If yes, what type? Are you taking in Estrogens? No Yes If yes, what type? Number of Pregnancies: Number of live births: Men only loss of erection painful erection discharge from penis goiter hypothyroid disease Grave s disease diabetes type adrenal gland problems Page 5 of 6

6 Musculoskeletal joint pain joint stiffness muscle pain arthritis joint replacements walker cane wheelchair Neurological migraines seizures memory problems numbness weakness tremor loss of balance tingling Blood and Lymphatics anemia leukemia prior transfusion bleeding disorder Psychological major depression (once): when? major depression (twice or more) last episode? post-traumatic stress disorder anxiety panic attacks bipolar disorder eating disorder (re: bulimia or anorexia) History of suicide attempts History of inpatient treatment History of drug/alcohol abuse Please do not write below this line OFFICE USE ONLY Provider signature/discipline: Date Page 6 of 6

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