Bariatric Surgery Intake Forms
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- Gwendoline Laura Preston
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1 Dear Prospective Client, Thank you for your interest in the Bariatric Program at UNC Healthcare. We are happy that you have made the first step at improving your health and look forward to working with you. Please call your insurance company to find out if weight loss surgery is a covered benefit. If you need assistance we are happy to help. If you are considering paying out of pocket for the surgery, please call us so we can discuss options with you. Complete the required paperwork attached, along with the medical release form, and mail it back to us at: Division of Gastrointestinal Surgery, ATTN: Bariatric Coordinator, UNC Department of Surgery, CB# 7081, Chapel Hill, NC Once we receive your application, we will set up an initial appointment for you. On your initial appointment you will meet with a Nurse Practitioner, Registered Dietitian, and Clinical Psychologist. This detailed visit will combine an informational video, followed by an individualized psychological screening, a nutrition evaluation, and a physical examination. Blood work may be ordered. After this appointment all your paperwork will be submitted to your insurance company for approval, this may take up to 6 weeks. Many insurance companies require supervised diet and exercise attempts for up to six months prior to covering your surgery. Once approved, we will set up an appointment with one of our surgeons for your pre-surgical evaluation and if appropriate, a surgery date will then be set. We look forward to meeting you, Dr. Timothy Farrell Dr. Meredith Duke Dr. D. Wayne Overby Tara Zychowicz, Nurse Practitioner Lisa Prestia RN, Bariatric Coordinator University of North Carolina Chapel Hill The Division of GI Surgery/Bariatrics Dept. of Surgery 4035 Burnett Womack CB 7081 Chapel Hill, NC office fax Page 1 of 7
2 I am interested in: Gastric Bypass or Gastric Band Revision or Sleeve Gastrectomy How did you hear about our program? Contact Information Patient: Patient Address: Patient Telephone: ( ) Patient Date of Birth: Referring MD: MD Address: MD Telephone: ( ) MD Primary MD: MD Address: MD Telephone: ( ) MD Psychologist: Address: Telephone: ( ) Insurance Carrier: State: Have you called to verify that Bariatric Surgery is a covered benefit? Does your insurance require a 6 month supervised diet? (be sure to ask) Your Current Height: Your Current Weight: BMI: Page 2 of 7
3 Bariatric History: How long have you been looking into having weight loss surgery? Have you ever been evaluated for weight loss surgery before? Yes / No When did weight become a problem for you? Child Teen Adult With pregnancy At what age did you first begin dieting: years old Are your family members heavy? Yes / No which ones? What do you feel has caused you to be heavy? Major Illness Major Stressor Medication Marriage Travel Trauma Divorce Food choices Inactivity Genetics Other What was your highest adult weight? Lbs. When? What was your lowest adult weight? Lbs. When? Eating patterns: Describe your eating habits: Do you skip meals? Yes / No If so, which? What do you drink? How often do you drink sugar sweetened beverages? Do you have any difficulty swallowing? Are you allergic or intolerant to any foods? Yes / No If so, which? Do you eat big meals, or having difficulty feeling full? Yes / No If so, which? How often do you eat outside of the home/ include fast food? x s a week Exercise or Activity: Describe your exercise habits: How often do you exercise? I don t Daily 2x/week 3x/week 4x/week What are your barriers to exercise? Can you walk up a flight of stairs without stopping? Yes/ No Do you get chest pain or shortness of breath on exertion? How far can you walk without stopping? <10 mins 15 mins 30 mins >30 mins Psychological Eating/ Problems: Do you have any mental health concerns? Have you ever been hospitalized for mental health illness? Are you experiencing any major life stressors currently? Do you ever have binges (eating a large amount of food in a short period of time)? Are you under the care of a psychologist/ psychiatrist/ counsellor? Do you take any medications for mental health reasons? If yes, who prescribes them for you? Sleep Describe your sleep habits: Do you have any difficulty sleeping? Have you ever been tested for sleep apnea? Do you wear a CPAP? Do you take sleep aides? Page 3 of 7
4 Weight Loss Attempts: Program Diet pills (any) Describe/ Year Months on Program Pounds Lost Comments Cost ($) Weight Watchers Liquid Diets (Optifast or Slim Fast, etc.) Low calorie diets Low carb diets or Atkins Jenny Craig or Nutri-system Fad diets Physician Monitored Diet Diet Clinics Hypnosis/ counseling Surgery Dietitian counseling OA Gym Memberships Exercise plans What diet/ weight loss plan has worked the best? What do you feel has been your biggest barrier to losing weight? Why do you want to have weight loss surgery now? What surgery are you most interested in having, and why? Page 4 of 7
5 Personal Health History: Medical Problems (Circle all that apply) Diabetes High Blood Pressure Sleep apnea Heart Disease Reflux/Heartburn High Cholesterol Stress Incontinence Gallstones Arthritis Chronic Pain Low back pain Changes in Period/ PCOS Glaucoma Blood Clots Kidney or Liver Disease Venous Stasis Heart Attack CHF COPD Asthma Depression Bipolar Disorder Stroke Any other Medical History/Hospitalizations: Surgical History (YEAR): Tonsillectomy Gallbladder removal Appendectomy C-sections Hernia Repair: Any other operations: Allergies: Current Medications: Medication Amount (mg) Frequency Since (year) Page 5 of 7
6 Social History: Where are you from? Where do you live now? Education: Describe your living arrangements? Marital status: Single Married Divorced Widowed Other Children: Any desire for children in future? Yes/ No Current Occupation: Employer: Years at this position: Can you take time off to recover? Are you on disability? If so, since when and for what reason? Who will help take care of you, if needed, after surgery? Habits: Do you take any vitamins, herbs, supplements: Do you (or did you) smoke? Yes No Quit years ago You must be nicotine free x 6 weeks before surgery Average daily tobacco habit: packs/day for years Do you drink alcoholic beverages? Yes No Quit years ago How much? Do you use recreational drugs? Yes No Quit years ago You must be drug and alcohol free x 6 weeks before surgery Do you have, or have you had, a problem with drugs or alcohol? Yes No Explain: Family History: Biological Father (alive or deceased) Age: Medical Hx: Biological Mother (alive or deceased) Age: Medical Hx: Extended Family (Siblings, Grandparents, your children): (list anything of importance) Page 6 of 7
7 Are you experiencing (currently): Recent unexplained weight loss or weight gain Fevers/Chills Night Sweats Dizziness Headaches Weakness Fatigue Coughing Wheezing Shortness of Breath Chest Pain Pressure in chest Palpitations Heartburn Snoring (apnea) Daytime Drowsiness Insomnia Trouble swallowing Constipation Change in Bowels/Bloody Stools Abdominal Pain Hernias Pain or difficulty Urinating Libido changes Skin changes Health Maintenance: Do you see a healthcare provider regularly? Do you see a dentist regularly? When was your last: Mammogram Pap smear Colonoscopy Prostate Exam Eye Exam Birth Control? Have you had any Routine Diagnostic Studies (please attach reports) Lab work Chest X-ray EKG Cardiology Tests Other: Have you attended an information seminar by one of our doctors? Will you, the patient, commit to careful follow-up with us for up to 5 years? Yes No _ Signature of Patient Date Page 7 of 7
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