Health History Questionnaire Medical / Nutritional

Transcription

1 SURGICAL PROCEDURE YOU ARE INTERESTED IN: LAPAROSCOPIC GASTRIC BYPASS (ROUX-EN-Y) LAPAROSCOPIC SLEEVE GASTRECTOMY UNDECIDED PERSONAL INFORMATION LAST FIRST: M.I.: DATE OF BIRTH: AGE: CITY: STATE: ZIP CODE: PHONE NUMBER WHERE CAN YOU BE REACHED OR RECEIVE A MESSAGE DURING THE DAY? HOME: CELL: WORK : OTHER: SPOUSE LAST FIRST: YOUR PRIMARY CARE PHYSICIAN PHYSICIAN PHONE: CITY: STATE: ZIP REFERRING PHYSICIAN (IF DIFFERENT FROM PRIMARY CARE PHYSICIAN) PHYSICIAN CITY: STATE: ZIP: PHONE: PRIMARY INSURANCE COMPANY INSURANCE COMPANY POLICY HOLDERS POLICY NUMBER: CUSTOMER SERVICE PHONE NUMBER: RELATIONSHIP TO PATIENT: GROUP/PLAN NUMBER: CONTACT PERSON: PROVIDER INQUIRY/PRECERTIFICATION PHONE NUMBER: Page 1 of 5

2 YOU WILL NEED TO CALL YOUR INSURANCE COMPANY TO ASK THE FOLLOWING QUESTIONS BEFORE YOUR FIRST APPOINTMENT. PROCEDURE CODES: DIAGNOSIS CODE: LAP ROUX-EN-Y GASTRIC BYPASS: CPT CODE: MORBID OBESITY: ICD-10 CODE: E66.01 LAP SLEEVE GASTRECTOMY: CPT CODE: (ICD-9 CODE: ) 1. REPRESENTATIVE AT INSURANCE COMPANY (NAME): 2. DATE OF CALL: / / (MM/DD/YYYY) 3. DO I HAVE BENEFIT COVERAGE FOR MEDICALLY NECESSARY WEIGHT LOSS SURGERY FOR MORBID OBESITY FROM MY INSURANCE COMPANY? YES NO 4. ARE ABOVE PROCEDURES (CODES LISTED ABOVE) COVERED IF I HAVE SURGERY AT THE UNIVERSITY OF MICHIGAN? YES NO 5. DOES MY WEIGHT LOSS SURGERY BENEFIT REQUIRE A MEDICALLY SUPERVISED WEIGHT LOSS TRIAL PROGRAM? YES LENGTH OF PROGRAM? NO SKIP TO NEXT QUESTION. 6. IS A PRIMARY CARE PHYSICIAN REQUIRED TO COMPLETE THE WEIGHT LOSS DOCUMENTATION OR CAN A SPECIALTY DOCTOR RECOMMEND AND FOLLOW THE WEIGHT LOSS TRIAL PROGRAM? 7. WHAT IS MY CO-PAY FOR A PRIMARY CARE OFFICE VISIT? $ 8. WHAT IS MY CO-PAY FOR A SPECIALIST CARE OFFICE VISIT $ 9. HOW MANY NUTRITION APPOINTMENTS WILL BE COVERED WITH THE DIAGNOSIS OF MORBID OBESITY? INDIVIDUAL GROUP 10. WHEN IS THE EFFECTIVE DATE OF THE POLICY? (MM/DD/YYYY) 11. IS A REFERRAL REQUIRED FROM MY INSURANCE COMPANY? YES NO 12. WHAT IS MY DEDUCTIBLE PER CALENDAR YEAR? $ HOW MUCH HAS BEEN MET? $ 13. WHAT IS THE MAXIMUM OUT-OF-POCKET COST PER CALENDAR YEAR? $ HOW MUCH PAID TO DATE? $ 14. WHAT IS THE CO-INSURANCE FOR MY POLICY? 15. WHAT IS MY IN-PATIENT SURGICAL CO-PAY TO THE DOCTOR? $ 16. WHAT IS MY OUT-PATIENT SURGICAL CO-PAY TO THE DOCTOR? $ 17. WHAT IS MY IN-PATIENT SURGICAL CO-PAY TO THE HOSPITAL? $ 18. WHAT IS MY OUT-PATIENT SURGICAL CO-PAY TO THE HOSPITAL? $ PATIENT S EMPLOYER: OCCUPATION OR TYPE OF WORK PERFORMED: Page 2 of 5

3 MEDICAL INFORMATION Circle Y for Yes and N for No for any of the following conditions in the past or present: Y N Diabetes: Type 1 Type 2 Gestational Y N Arthritis, joint pain: Y N High blood pressure knees hips ankles Y N High cholesterol Y N Heart disease / Heart attack Date of heart attack: Bypass Stent Angioplasty wrist hands Other: Y N Chronic low back pain Y N Mobility assistance. If Yes, do you use a: Cane Walker Wheelchair/Scooter Y N Chest pain, angina Y N Heart failure Y N Have you ever had Blood Clot, Deep Vein Y N Stroke / CVA / TIA Y N Sleep Apnea If Yes, do you use: CPAP BiPAP Y N Asthma Y N Emphysema / COPD Y N Thyroid disease Hypothyroidism Hyperthyroidism Thrombosis(DVT), or Pulmonary Embolism(PE)? DVT: Date(s): Reason: PE: Date(s): Reason: Y N GERD, reflux, heartburn, indigestion Y N Do your religious beliefs allow blood transfusions Y N Ulcers: Stomach / Esophagus / Small intestine if medically necessary? Y N Crohn s Disease, Ulcerative Colitis, Colitis Y N Have you ever had Blood transfusion(s)? Y N Irritable Bowel Syndrome Date(s): Y N Gallbladder disease / Gallstones Gallbladder removed? Yes No Y N Hepatitis: B C Autoimmune Y N Fatty liver disease Y N Have you had an X-ray, CT/CAT scan, ultrasound, or other radiology study of your esophagus / stomach / abdomen? Date: Abnormalities: Y N Cancer, type: Date Diagnosed: Surgery date and type: Radiation (Date completed): Chemo (Date completed): Y N Lupus Y N Have you had an upper endoscopy / EGD / Scope within the past 3 years? Date: Abnormalities: Y N Kidney Disease Y N Hernia, type: Y N Urinary incontinence Y N Polycystic ovarian syndrome Y N Previous Transplant Y N If female, date of last menstrual period: Heavy menstrual bleeding Yes No Y N Previous bariatric surgery Gastric bypass Sleeve gastrectomy Lap band placement Other: Has it been repaired? Yes No Type: Followed by: Y N Psychological Diagnosis (Past or Present): Anxiety Depression Panic Attacks Bipolar Disorder Other: Page 3 of 5

4 Height / Weight Current height (in inches): At what age did your weight became a problem? Current weight (in pounds): Highest weight (in pounds): Surgeries: Please include the dates Your desired goal weight (in pounds): Date Surgery Date Surgery Medications: What medications do you take on a regular basis? Include any over-the-counter herbal, vitamins, minerals, and prescription drugs. Medication Dosage How Often Why do you take it? (mg/iu/gm, etc.) (times/day) ALLERGIES: Are you allergic to any drug, food or substance (Example: Latex)? If yes, what happens when you take or are exposed to it? Drug/Food/Substance Reaction Page 4 of 5

5 SOCIAL HISTORY Gender: Male Female Marital Status: Single Married Divorced Other Do you have children? Yes No Ages: Are you breastfeeding, pregnant, or looking to become pregnant in the next 12 months? Yes No Tobacco Products: Do you use, or have you ever used any tobacco products? Yes No Quit If yes: cigarettes chew pipe smokeless How much used per day? Year you started? If you quit, when? Alcohol: Do you drink any alcoholic beverages? Yes No How many alcoholic beverages do you consume: Daily Weekly Monthly History of Drug Use? Yes No If you quit, when? If yes, type(s) of drugs: WEIGHT LOSS ATTEMPTS Please indicate all weight loss attempts you have tried. Check all the boxes that apply. Atkins LA Weight Loss Registered Dietician Calorie counting Laxatives Shapedown Exercise Liquid diet Slim Fast Grapefruit diet Low / no carb diet South Beach hcg injections and diet Medical Weight Loss Clinic T.O.P.S. HMR Nutrisystem Vomiting after eating Hunger Within Workshop Portion control Weight Watchers Jenny Craig Other (please list): WEIGHT LOSS MEDICATIONS Please indicate all weight loss medications you have tried. Check all the boxes that apply. Adipex (phentermine hydrochloride) Green tea supplements Meridia (Sibutramine) Alli (Xenical or orlistat) Hoodia Phentermine (Fen-Phen) Byetta (exenatide) Hydroxycut Quick Slim Dexatrim Other (please list): Printed Name of person who completed this form / / Date (mm/dd/yyyy) Page 5 of 5