Rush Bariatrics Health Survey
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- Rudolf May
- 7 years ago
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1 Welcome to our Health Survey This health survey will help us understand more about you and make the most of your first visit with our team. Your responses will help us determine the best strategy for you to manage your weight and if bariatric surgery is the right option. We would like to know more about you and how you have been managing your weight until now. Please complete the following information as accurately as possible. First name M.I. Last name Gender Date of birth Marital status Number of children Referring doctor Date of last physical exam Current weight Height Feet Height Inches Lowest adult weight Number of years overweight Highest adult weight When did you lose this weight? How long did you keep this weight off? Previous Diet Attempts Supervised Diet Attempts (Check all that apply) Diet Pills from MD Diet Center T.O.P.S. Nutri-System Supervised Calorie Counting by Health Professional Overeaters Anonymous Optifast Weight Watchers Jenny Craig Other Non-Supervised Diet Attempts (Check all that apply) Dr. Atkins Low Fat Health Spa Metabolife Sugar Busters Grapefruit Diet Scarsdale Diet Hypnosis Accutrim Richard Simmons Cabbage Soup Dexatrim Gastric Bubble Mayo Clinic High Protein Diet SlimFast Pritikin Diet Other 1
2 Medical History Please tell us about your personal medical history and surgical history. We also would like to know about medical conditions affecting family members. In the last two sections, please tell us more about you and your health habits. Personal Medical History (Select all that apply) Anemia Depression Hypertension Arthritis Diabetes Mellitus Kidney Disease Asthma Emphysema Myocardial Infarction Cancer Endocrine Problems Peptic Ulcer Disease Crohn s Disease Congestive Heart Failure GERD Seizures Clotting Disorder Glaucoma Stroke Hepatitis HIV / AIDS Sleep Apnea Chronic Obstructive Pulmonary Disease Medications Allergies Personal Surgical History (Select all that apply) Adrenal Gland Surgery Coronary Artery Bypass Graft Neck Surgery Appendectomy Esophagus Surgery Prostate Surgery Bariatric Surgery Gastric Bypass Surgery Small Intestine Surgery Breast Surgery Hemorrhoid Surgery Spine Surgery Cesarean Section Hernia Repair Stomach Surgery Cholecystectomy Hysterectomy Thyroid Surgery Prior Surgeries Comments Family History (Select all that apply) Anemia Cancer Stroke Diabetes Hepatitis Heart Disease Blood Clot Anesthesia Reaction Bleeding Problems High Blood Pressure 2
3 Social History Employment Status (Select one) Full Time Part Time Self Employed Unemployed Occupation Social History (Select all that apply) Tobacco use? If yes, how many packs per day Alcohol use? If yes, number of drinks per day Drug use? If yes, type / frequency Cancer Health Habits (Select all that apply) Breast ly Self-Exam ly Physical Exam Date of Last Mammogram Colon ly Rectal Exam ly Stool Test for Blood Date of Last Sigmoidoscopy Skin High Sun Exposure ly Skin Exam Date of Last Colonoscopy GYN ly GYN Exam ly PAP Smear Prostate ly PSA Blood Test ly Rectal Exam 3
4 Current Medical Conditions Please tell us about any symptoms or conditions you currently experience. General Fever Fatigue Unexplained Weight Loss Cardiovascular Chest Pain (Angina) Palpitations Heart Valve Problems Calf Pain with Walking Swelling of Legs Digestive Loss of Appetite Nausea / Vomiting Difficulty Swallowing Blood in Stool Diarrhea Constipation Heartburn Eat Satiety (fill up easy) Dark, Tarry Stools Abdominal Pain Painful Bowel Movements Musculoskeletal Joint Pain / Swelling Muscle Weakness Back Pain Psychiatric Anxiety Depression Mood Swings Hematologic / Lymphatic Prior Transfusion Easy Bleeding or Bruising Swollen Glands Eyes / Ears / Nose / Mouth / Throat Glasses / Contacts Blurred or Double Vision Eye Disease or Injury Hearing Loss / Ringing Nose Bleeds Bleeding Gums Sore Throat Recent Voice Change Antibiotics for Dental Work Respiratory Chronic Cough Coughing Up Blood Short of Breath Lying Flat Shortness of Breath on Exertion Neurologic Frequent / Recurring Headaches Decreased Sensation Paralysis Difficulty with Speech Skin / Breast Rash / Itching Ulcers or Sores Yellowing of the Skin Breast Lump Breast Pain Nipple Discharge Endocrine Excessive Thirst or Urination Heat / Cold Intolerance Allergic / Immunologic HIV Infection Low White Blood Cell Count Genitourinary (Males) Painful / Burning Urination Blood in Urine Gas or Stool in Urine Leakage of Urine Change in Force or Stream 4
5 Epworth Sleepiness Scale How likely are you to doze off in the following situations, in contrast to feeling tired? Even if you have not done some of these activities recently, try to remember how they have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Situation Chances of Dozing Sitting and reading Watching TV Sitting, inactive in a public place (e.g. a theater or meeting) As a passenger in a car for an hour without break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic 5
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Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete