Bariatric Surgery Program Questionnaire

Transcription

1 Bariatric Surgery Program Questionnaire Patient Name: Date: Information Session Date: PERSONAL DEMOGRAPHICS Last Name First Name MI Maiden Name Address City State Zip *Home Phone Cell Phone Work Phone *Please check next to the phone number that is the best number you can be reached on during the day Male Female Date of Birth: Married Divorced Widowed Separated Never Married Race: White African American Hispanic Asian Native American/Alaskan Native Other address (This is only if you wish to receive communication via .) Employer SPOUSE INFORMATION: Last Name First Name Phone Number Employer PRIMARY INSURANCE COMPANY Insurance Company Name Address City State Zip Policyholder s Name Relation to Patient Policy Number Group/Plan Number Customer Service Phone Number Provider Inquiry/Pre-Certification Phone # Contact Person Is Gastric Bypass, Gastric Banding, and/or Sleeve Gastrectomy for Clinically Severe Obesity a covered benefit? Yes No Please check the surgery that you are interested in having: Gastric Bypass Sleeve Gastrectomy Gastric Banding I have not decided on a procedure AAmann/BariatricSurg/4.1.16/2019

2 SECONDARY INSURANCE COMPANY Insurance Company Name Address City State Zip Policyholder s Name Relation to Patient Policy Number Group/Plan Number Customer Service Phone Number Provider Inquiry/Pre-Certification Phone # Contact Person Is Gastric Bypass, Sleeve Gastrectomy, and/or Gastric Banding for clinically severe obesity a covered benefit? Yes No YOUR PRIMARY CARE PROVIDER Primary Care Provider Address Phone Fax REFERRING PROVIDER Referring Provider Address Phone Fax PERSONAL STATEMENT Please tell us, in your own words, why you are asking to have weight loss surgery the effects of weight on your health, employment, social life, etc. Please use extra paper, if necessary. 2

3 PERSONAL STATEMENT continued 3

4 DIET HISTORY Current Weight: Current Height: Weight at 18 years of age: Goal (desired) weight: 1. Record ALL weight loss attempts, especially weight loss that was medically supervised (i.e. supervised by a physician, advanced practice clinician (e.g. physician assistant, nurse practitioner, etc.), or registered dietician). Most insurance plans require prior attempts at weight loss to qualify for surgery. 2. Start with your first diet and proceed until the most recent one. 3. Please include weight-loss medications such as Apidex, Redux, Meridia, or Xenical, Alli, Qsymia, Adipex (Phentermine). YOU WILL NOT BE SCHEDULED FOR AN APPOINTMENT WITHOUT COMPLETION OF THIS DIET HISTORY SECTION. Year Age at start of diet How long were you on this diet? Weight at start of this diet? Weight lost on this diet? What kind of diet were you on? Doctor or dietician who supervised this diet. 4

5 MEDICAL INFORMATION PAST MEDICAL HISTORY Do you have, or have you had, any of the following? Diabetes Hypertension (High blood pressure) High cholesterol Chest pain or angina Heart failure Heart attack, when? Chronic obstructive pulmonary disease/copd (Emphysema) Vitamin D deficiency Asthma Sleep Apnea Do you use - CPAP BiPAP? Settings (cm H20): _ Do you use oxygen with CPAP/BiPAP YES NO How many Liters? _ Arthritis, joint pain? Where? Gastroesophageal reflux disease/gerd (Heart burn or indigestion) Anxiety History of blood clots or bleeding disorders Depression Cancer, what kind? When? Surgical Radiation Chemotherapy Crohn s disease, colitis, or bloody diarrhea? Irritable bowel syndrome Hernia, what kind? Gallbladder trouble (if not surgically absent) Iron deficiency Stomach ulcers Thyroid disease Fatty liver disease Hepatitis B or C? HIV Lupus Polycystic ovarian syndrome (PCOS) Women: Last menstrual cycle date? Menopause? YES NO Problems with anesthesia Other: PAST SURGICAL HISTORY Date of Surgery Surgery 5

6 MEDICAL INFORMATION continued FAMILY HISTORY FAMILY HISTORY OF: NO YES WHAT RELATIVE(S)? & WHAT AGE(S)? (Maternal/Paternal) 1. Heart Disease 2. High Blood Pressure 3. Lung Disease 4. Diabetes 5. Stroke 6. Kidney Disease 7. Thyroid Disease 8. Cancer 9. Family History of blood clots or bleeding disorders 10. Crohn s Disease, Ulcerative Colitis or bloody diarrhea 11. Have any of your family members had bariatric surgery? SOCIAL HISTORY Do you or have you in the past used any tobacco products? YES NO If so, what kind? How often? (ex: ½ pack per day) What year did you start? Quit date: Do you drink alcohol? YES NO If so, how much of the following do you drink per week? Mixed drinks (1 oz/drink) Beer (12 oz) Wine (6 oz glass) Do you use recreational drugs? YES NO If yes, which drugs and how often? Occupation Does your job require night shift work? YES NO Do you use a wheelchair? YES NO How many hours per day? Do you use oxygen? YES NO How many Liters/minute? How far do you walk in a normal day (miles, blocks, steps)? How many steps can you climb? How many steps do you climb daily? How many hours drive do you live from University of Utah Hospital? Are you able to drive yourself to appointments? YES NO Who lives with you? Who will look after you while you are recovering from surgery? PREGNANCIES Please list pregnancies: approximate dates and outcome Date Outcome (e.g., full term, premature, C-section, abortion, miscarriage) 6

7 MEDICAL INFORMATION continued REVIEW OF SYSTEMS (please check all that apply to you) 1. Constitutional symptoms: None Fever Weight loss Weight gain Fatigue Other: 2. Eyes: None Dry eyes Red eyes Painful eyes Change in vision Other: 3. Ears, Nose and Throat: None Sore throat Sinus congestion Sinus pain Hay fever Toothache Deafness Hoarseness Lump or mass Dry mouth Other: 4. Heart: None Chest pain Chest pressure Swelling feet/legs Palpitations Murmur Waking up short of breath Other: 5. Lungs: None Wheezing Cough Sputum Shortness of breath at rest With exertion Other: 6. Stomach and Intestines: None Heartburn Nausea Vomiting Abdominal pain Frequent constipation Frequent diarrhea Hemorrhoids Bowel incontinence Other: 7. Kidneys and Bladder: None Impotence Difficulty with urination Abnormal vaginal bleeding Menstrual irregularity Infertility Arising at night to urinate Pain or burning on urination Bladder incontinence Other: 8. Muscles and skeleton: None Joint pain: (which) Muscle pain Joint swelling Back pain Other: 7

8 MEDICAL INFORMATION continued REVIEW OF SYSTEMS continued (please check all that apply to you) 9. Skin: None Rash Nodule Other: 10. Brain and Nerves: None Weakness Tremor Numbness Incoordination Fainting Depression Anxiety Headaches How often? Other: 11. Glands: None Excessive thirst Low blood sugar High blood sugar Low blood pressure High blood pressure Other: 12. Breasts: None Pain Lump/Mass Nipple retraction Discharge Other: ALLERGIES Are you allergic to any drug, food, or substance? If yes, what happens when you take or are exposed to it? (Example: Penicillin rash) Drug, Food, or Substance Reaction 8

9 MEDICAL INFORMATION continued MEDICATIONS What medications do you take on a regular basis? Include over-the-counter (e.g., Tylenol, Ex-Lax), herbal (e.g., St. John s Wort, glucosamine-chondroitin), and vitamin-mineral supplements (e.g., Calcium, One-A-Day). Name Dosage (e.g., mg ) Frequency (times per day) Why do you take it? 9