Date: First Name: Last Name: Date of Birth: / / Age: Sex: M F Race: Mailing Address: City: State: Zip: Social Security :

Transcription

1 MEDICAL AND PATIENT INFORMATION QUESTIONNAIRE (DOC-01) PATIENT INFORMATION Date: First Last Date of Birth: Age: Sex: M F Race: Mailing City: State: Zip: Social Security : Contact information Home phone ( ) - Work phone ( ) - Cell Phone ( ) - Fax ( ) - Best way to contact you (check all that apply) Marital Status: Single Married Domestic Partner Divorced Widowed Years Spouse or Significant Other s Children: Yes No Ages Education: High School Some College College Graduate Graduate Degree Professional Degree Pharmacy: City: State: Zip Phone number: Fax number: EMPLOYMENT Occupation: Employer: Employer Work Phone: ( ) - May we contact you at work? Yes No EMERGENCY CONTACT INFORMATION Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - City: State: Zip: Page 1 of 5

2 REFERRING OR PRIMARY CARE PHYSICIAN Phone: ( ) - Fax: ( ) - City: State: Zip: Have your discussed weight loss surgery with your Physician? Yes No Date of Last Complete physical exam Lab Work (Blood Test) Chest X-Ray / EKG Pap Smear/ Mammogram Female Patients Only Age of first period Regular: Yes No Date of last Menstrual Cycle Number of pregnancies past first trimester / Live birth / Social Habits Ever used How much Since (date) If stopped when (date) Smoking Yes No Other tobacco Yes No Alcohol Yes No Other drugs (specify) Weight Loss Programs You Have Tried Jenny Craig Atkins Acupuncture MediFast/ OptiFast Nutrisystem Phen Fen Slim Fast Weight Watchers Xenical Metabolife Meridia Redux Other Can you provide the records or receipts for any of the above programs: Yes No Height /Weight information Provide the best estimate Height Weight Height/Weight in Jr. High School Height/Weight in High School Lowest weight as an adult Page 2 of 5

3 Highest weight as an adult Your Last known Family members >50 lbs over weight Allergies Medication or Food Symptoms (Nausea, shortness of breath etc) Medications (may attach a list if available) Name Dosage and frequency Previous Surgeries Operation (including C-section) Date Past Medical problems Circle all that apply (Diagnostic codes are for internal use) Cardiovascular Arrhythmia -Irregular heart rhythm History of Hearth Attack V12.53 Musculoskeletal Arthritis weight bearing joints Joint pain weight bearing joints Page 3 of 5

4 High Blood Pressure (HTN) Poorly controlled Congestive heart failure (CHF) Venous insufficiency (peripheral) Varicose veins Swelling of ankles Gastrointestinal Difficulty swallowing Reflux Disease (GERD) Heartburn Hiatal Hernia Cholelithiasis -Gall stones Cholecystitis- Pain with Gall stones Hepatitis Fatty liver Endocrine Diabetes Mellitus type II Poorly controlled Hypothyroidism Hyperlipidemia High Triglycerides - Hypertriglyceridemia High Cholesterol - Hypercholesterolemia Low Calcium - Hypocalcemia High Calcium Hypercalcemia Hyperparathyroidism Hypoglycemia, unspecified Iron deficiency anemia low dietary-absorption Lactose intolerance Vitamin deficiencies multiple Vitamin B12 deficiency Vitamin D deficiency Respiratory System Asthma unspecified Diagnostic symptoms for sleep apnea- hyponea Daytime sleepiness Frequent awakening Morning headaches Night sweats Snoring Primary Central sleep apnea Sleep related hypovent./hypoxemia Snort or gasp- at night wakes you up Obstructive sleep apnea Unspecified sleep apnea Joint pain Back Joint pain Foot Joint pain Hip Joint pain Knee Low back pain Sciatica Neuro-Psycho-Social conditions-stressors Anxiety disorder Bipolar disorder Depression 311 History of abuse, emotional V15.42 History of abuse, physical V15.41 History of alcohol abuse V11.3 Panic disorder Stress (General) Pseudotumor Cerebri General complaints and Complications of previous WLS (if any) Abdominal pain RUQ 01, LUQ 02, RLQ 03, LLQ 04 Anemia Anorexia (loss of appetite) Bezoar Obstruction Food blockage Complications of device Dehydration Diarrhea following bowel surgery Disorders of calcium metabolism Dumping syndrome Fistula gastrointestinal537.4 Fistula post-op persistent Gastric outlet obstruction/stenosis Gastroesophageal reflux Hair loss Hematemesis (vomiting blood) Malnutrition of mild degree Malnutrition of moderate degree Nausea Protein-calorie malnutrition Pulmonary Embolism post operative Small bowel obstruction Incisional Hernia Hernia Ventral Others not listed (write in please): Page 4 of 5

5 Urinary Frequent urination Urinary stress incontinence Female Urinary stress incontinence Male Gynecological Heavy periods Amenorrhea (no periods) Infertility Irregular periods Dysmenorrhea Painful periods Polycystic ovary disease MISCELLANEOUS INFORMATION Do you take Vitamins? Yes No Daily? Yes No Do you smoke? Yes No Number of packs Number of years Quit? Yes No When? Do you drink any alcoholic beverages: Yes No If yes, Type: Do you or have you used any illicit drugs: Yes No Type: How Long: When was the last time you used: Do you live alone: Yes No Do you care for young children or any elderly: Yes N List household members (Names & ages): The information completed in this packet is true and correct to the best of my belief Print your name: Date: Signature: w Page 5 of 5