Surgical Weight Loss Center Patient Intake Form
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- Collin Short
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1 Surgical Weight Loss Center Patient Intake Form Dear Patient, Please completely fill out the following history form to the best of your abilities. It provides us with important information regarding your health and candidacy for weight loss surgery. If you have a lengthy surgical history or you are on multiple medications, you may write these items on a separate page. Please be sure to bring this with you to your first appointment. Without it we will need to reschedule your visit. Thank you. Name: Address: Phone: Day: Evening: Who may we thank for referring you? Obesity Related Co-morbidities Severity of Symptoms: Please circle the answer that applies to you Mild (symptoms are bothersome/hardly affect my daily living) Moderate (symptoms are difficult to tolerate/affect my daily living) Severe (symptoms affect my daily living) Onset of weight gain: Childhood Adolescence Adulthood After Childbearing 1
2 Are you at your maximum weight now? Do you have diabetes? (year of diagnosis: ) t currently, but have in the past Do you take insulin? Do you check your sugars at home? What are they? Have you suffered from any diabetic complications? (ex. Nerve damage, vision changes, foot ulcerations.) Do you have COPD? (year of diagnosis: ) Do you use oxygen? (setting: ) t currently, but have in the past Do you use this during the day or night? Do you have asthma? (year of diagnosis: ) t currently, but have in the past Have you ever been hospitalized for asthma treatment? Do you have obesity hypoventilation syndrome? (year of diagnosis: ) t currently, but have in the past If yes, who is your treating physician and what is your treatment plan? 2
3 Do you have sleep apnea? (year of diagnosis: ) t currently, but have in the past Have you had a sleep study? Do you use CPAP or BiPAP? (setting: ) Where and when were you tested? Have you ever had a deep vein thrombosis (DVT) or a pulmonary embolism (PE)? If so, when did this occur? How was this treated? Do you have hypertension (high blood pressure)? (year of diagnosis: ) t currently, but have in the past Have you suffered any complications from hypertension? (ex. Stroke, kidney problems.) Have you had a heart attack? Have you ever had heart surgery or a stent placement? Do you have high cholesterol or triglycerides? (year of diagnosis: ) t currently, but have in the past 3
4 Do you have heartburn or gastro esophageal reflux disease (GERD)? (year of diagnosis: ) t currently, but have in the past How often do you take medication for this? Have you ever had tests for this? (ex. Endoscopy in which a camera is placed in the stomach.) If so, when and where was this done? What were the results? Have you suffered from any complications related to GERD? (ex. Barrett s esophagitis, anemia.) Have you ever been treated for ulcers? Have you ever been treated for h. pylori? Have you ever had gallbladder disease? Do you have urinary stress incontinence (leakage of urine when laughing, sneezing or coughing)? (year of diagnosis: ) t currently, but have in the past Do you wear pads? How often? Do you have a connective tissue disorder or autoimmune disease? (ex. Lupus or Ehlers-Danlos Syndrome.) Do you use steroids for a chronic condition? 4
5 Do you have chronic joint pain or arthritis? (year of diagnosis: ) t currently, but have in the past Where is it located? Is your mobility limited all or most of the time? Is your activity limited by pain? Do you take daily medication for this? Have you had surgery for this or is surgery planned in the future? Have you ever had an eating disorder? What type? (ex. Anorexia, bulimia, binge eating.) Have you undergone treatment? Do you suffer from depression or another mental health problem such as bipolar or anxiety disorder? What type? Are you involved in therapy or a support group? Do you take medications for this? Have you ever considered harming yourself or others? 5
6 Do you have gout? Do you have PCOS (polycystic ovarian syndrome)? Past Medical History Primary Care Provider? Telephone: Fax: Address: Date of last PAP smear/pelvic exam: Was it normal? Date of last mammogram: Was it normal? Any abnormalities in the past? Treatment: Date of last colonoscopy: Was it normal? Any abnormalities in the past? Treatment: Date of last stress test: Date of last EKG: Was it normal? Was it normal? Date of last echocardiogram (ultrasound of the heart): Was it normal? 6
7 Have you ever had any of the following? If yes, please describe. Rectal disease Jaundice Hepatitis HIV Frequent infections Cancer Anemia Heart Problems Colitis, Bowel Disease, Crohns, Ulcerative colitis Thyroid disorder Respiratory Problems Infertility Severe Headaches Miscarriage (how many? ) Blood Transfusion Surgical History Please list any surgeries you have had, including the year
8 Family History (please list only if applicable to your parents, siblings, or grandparents) Do you have a relative with cancer? Who: What type? Do you have a relative with heart disease? Who: Do you have a relative with a blood clotting disorder? Who: Do you have a relative who has had a stroke? Who: Do you have a relative with diabetes? Who: Do you have a relative with obesity? Who: Social History Marital status: Single Married Widowed Divorced Is your spouse supportive of your desire for weight loss surgery? If no, please explain Education: High School GED College Post-graduate Occupation: Do you smoke? t currently, but have in the past For how many years? How many packs per day? Time since quitting? Do you drink alcohol? t currently, but have in the past Do you use recreational drugs? t currently, but have in the past What type? Have you ever had a problem with substance abuse? Do you consider yourself to be a sweets eater? 8
9 Gynecological History Do you use hormone replacement therapy? t currently How many children do you have? How many vaginal deliveries? How many C-sections? Do you use any contraception (birth control)? t currently Have you undergone infertility treatment? If yes, please describe treatment Medications 1. Drug Name Dose Frequency
10 Please list any non-prescription medications or herbal supplements: Are you allergic to any medications? Please list medication and reaction: Weight Loss History How many weight loss attempts have you made in your life? >25 Among the following exercise programs, please provide information for those you have tried: Months on Program Weight Loss Weight Gain Health Club Walking Jogging Bicycling Swimming Aerobics Personal Trainer Physical Therapy Other Among the following weight loss programs, please provide information for those you have tried: Months on Program Weight Loss Weight Gain Fen-Phen/Redux 10
11 Months on Program Weight Loss Weight Gain Xenical Meridia Medifast Nutrisystem Weight Watchers Jenny Craig Metabolife Herbalife Richard Simmons Atkins Sugar Busters Slim Fast Slim for Life Overeaters Anon. Hypnosis Acupuncture Nutritionist Psychotherapy Behavior Mod Wired Jaw Surgery South Beach Diet The Zone Alli Metabolic Research Center Colorado Weigh LA Weight Loss HCG Diet Blood Type Body for Life Other Have you ever had a physician monitored weight loss plan? 11
12 OFFICE USE ONLY BELOW BP TEMP HR RR O2 SAT WEIGHT HEIGHT BMI IDEAL WT. Obesity Related Co-morbidities Other PMH
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Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology 2310 Myron Drive Raleigh, North Carolina 27607 P: (919) 782-9536 F: (855) 787-8025 Name: SSN: Date of Birth (mmddyy):
Review of Systems. Eye/Ear/Nose/Throat. hard to empty bladder. palpitations/irregular heartbeat. persistent cough, wheezing. feelings of depression
Name: Review of Systems DOB: / / For staff: place patient label here. Check here if no symptoms. Check concerns below only if you have experienced symptoms recently. General loss of appetite abnormal weight
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684
Alldent Dental Center Patient Registration
Patient Registration DATE Patient Name Age Address Home Phone Cell City State Zip Email Social Security # Date of Birth Sex: M F Single Married Divorced Widowed Separated Employed by Occupation Business
Office Locations. Website: www.chrias.com. Phone number: 302-892-9900. Fax number: 302-892-9980
Office Locations Newark 537 Stanton-Christiana Road Suite 102 Newark, DE 19713 Office Hours: Monday-Friday 8:00 am to 4:00 pm North Wilmington Concord Plaza Office 3521 Silverside Road Quillen Bldg, Suite
PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date:
WORKERS COMPENSATION HISTORY PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: Address: City: State: Zip:
General Internal Medicine Clinic New Patient Questionnaire
General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM Today s Date: PERSONAL INFORMATION First Name: Last Name: MI: Address: City: State/Province:
Weight Loss Surgery Information Session. WFBH Bariatric Surgery Program
Weight Loss Surgery Information Session WFBH Bariatric Surgery Program What makes us different? Center of Excellence (COE) High volume center > 1000 procedures since 2003 Less complications than non-coe