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Lap Band Patient Packet Dear Prospective Patient Thank you for considering Dr Clay Wellborn to help you take control of obesity and your life Our h ighly trai

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Lap Band Patient Packet Dear Prospective Patient Thank you for considering Dr Clay Wellborn to help you take control of obesity and your life Our h ighly trai Powered By Docstoc
					                           Lap-Band Patient Packet




Dear Prospective Patient:

Thank you for considering Dr. Clay Wellborn to help you take control of obesity and your life. Our h ighly trained
team is committed to providing the highest level of patient care every step of the wa y. Dr. Wellborn was the first
surgeon in Little Rock to offer the Lap-Band system and has done more than 2000 Lap-Band procedures. He has
been doing Bariatric Surgery since his residency and has done more than 5,000 weight loss surgeries. He is board
certified and holds active memberships with American Medical Society for Bariat ric Surgeons and the Arkansas
Medical Society, and is a clin ical instructor teaching residents from UAMS.

If you have tried non-surgical weight loss therapies without success, weight loss surgery may be your solution.
Studies demonstrate that weight loss surgery yields the longest period of sustained weight loss in patients who have
failed other non-surgical therapies. For best results, we have found patients need to actively participate in a mult i-
disciplinary weight loss program, which includes nutritional, emotional and exercise counseling.

If you are interested in pursuing the Lap-Band surgery, please read the materials provided in this packet and
complete the enclosed Patient Worksheet. Once you have completed the forms, make a copy for yourself and send
or fax to the address at the top of this letter. Please note that this is not an overnight process, as it requires steps that
involve mult iple part ies. We will make every effort to exped ite this process for you, and we ask that you do not
make unnecessary phone calls to inquire about your case status.

In the meantime, you can begin taking positive steps toward your post -surgical success. Read the literature provided
on the Web site. Refer to the checklist included in this packet and make sure everything is completed before we see
you in the office. The more information you provide us with, the easier it will be for us to obtain authorization fro m
your insurance company for your s urgery.

We look forward to help ing you achieve your health goals.

Sincerely,


J. Clay Wellborn, Jr., M.D.

And office staff:
Suzan Wellborn, Program Coordinator ext . 106
Leslie Beckham, Su rgical Coordinator; ext. 108
Jamie Calvert, Patient Coordinator; ext. 111
Nico le Rucks, Pat ient Relations/Self Pay patients; ext. 110
Lee Cav iness, Scheduling; ext. 100




                                                                  1
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Lap-Band Patient Checklist
Before you can be scheduled for a history and physical with Dr. Wellborn you must have
completed everything below. We receive a high volume of calls. If you need assistance with
this form, please e- mail Leslie at leslie@arkansasobesitysurgery.com. She will get back with
you as soon as possible. Please return these forms completed. Thank You.



Name

Date                                                                     Phone

Primary Care Physician

I was referred by

(Ad, Internet, friend, family member, physician, other — please list)



Checklist


  Filled out packet and returned it to the Wellborn Clinic. (insurance & self pay) 
 Copied packet and saved it in my files on (date)                              .


  Co mp leted New Pat ient Registration Portal on line (date)________________. (insurance & self pay)
 Sent copy of front and back of insurance card to the Wellborn Clinic. (insurance)







  Called my insurance company and used the form provided. (insurance)
 Verified that my insurance would approve code 43770 without exclusion. (insurance patients)




 Attended the Lap-Band seminar on (date)                                       . (insurance & self pay patients) 
Attended support group meeting on (date)____________________________. (insurance & self pay patients)




 Viewed EMMI (Leslie or Tonya will schedule this.) (insurance & self pay patients)




 Received referral fro m primary care doctor (if required by insurance).
 Received Primary Care Letter of Necessity (an examp le included in packet). (insurance patients)




Signed a release of med ical in formation and sent Dr. Wellborn at least 2
  years of med ical h istory (and any other relevant medical informat ion fro m
  any physician i.e. OB, orthopedic, cardio logist etc. (insurance & self pay

  patients)




 Had my psychiatric evaluation (if required by insurance, or on psychiatric drugs) on (date)

               .
 Had my labs drawn at
                
                                                    on (date)                  . (insurance & self pay patients)
 Faxed labs to the Wellborn Clin ic on (date)
         
                                                                               . (insurance & self pay patients)


Once surgery is scheduled, you will be set up for:

Nutritional evaluation
Pre-op testing at hospital
Surgery instructions




                                                                  2
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
                 Records Release Authorization




I hereby authorize and request that medical records be released to the following person:

          Dr. J. Clay Wellborn, Jr.,
          #1 St. Vincent Circle, Suite 320
          Parkv iew Building
          Little Rock, A R 72205
          Phone 501.663.9600
          Fax 501.663.0465


Start date of requested records _________________________________ to Present date _______________________

Name

Address

Signature of Pat ient                                                                         Date

Signature of Witness                                                                          Date




Thank You For Your Cooperation,



J. Clay Wellborn, Jr., M.D.
General and Bariatric Surgery




                                                                  3
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
                       Advance Beneficiary Notice




Physician Notice

We do everything possible to insure coverage by your insurance company for your Laparoscopic Banding
Procedure. We submit prior authorizat ion letters and request written responses of approval. We pre -cert ify and
document everything.

It is still necessary for you to understand that if, for any reason, your insurance company does not cover payment,
you are personally responsible for all bills incurred fro m all physician/suppliers with regard to your procedure.



Beneficiary Agreement

I have been notified by my physician of the above statement and agree to be personally and fully responsible for
payment.




Signed                                                                              Date

Witness                                                                             Date




                                                                  4
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Patient Education Pre-Op Quiz
Please circle the correct answer to the questions below. All questions should be answered
to the best of your ability at your current level of knowledge about the lap band.



Patient’s Name                                                 Date

Surgeon’s Name                                                 Surgery Date



1.   Which one of the following materials is used to adjust the Lap -Band System?
     a.   Contrast med iu m.
     b.   Bariu m.
     c.   Water.
     d.   Saline.
     e.   Gas.

2.   What are the advantages of the Lap-Band System? (circle all that apply)
     a.   Weight loss is achieved through malabsorption.
     b.   The band can be adjusted.
     c.   It is less invasive than other surgical techniques.
     d.   Weight loss in the first year is rapid.
     e.   The process can be reversed.
     f.   Recovery may be quicker.

3.   It is appropriate to remove fluid fro m the Lap-Band in the following circu mstances:
     (circle all that apply)
     a.   During pregnancy.
     b.   For med ical reasons.
     c.   After a patient reaches his/her goal weight.
     d.   For a party or before a large meal.
     e.   Never.

4.   Lap-Band surgery is major surgery that requires anesthesia and post-op recovery.
     a. True.
     b. False.

5.   Risks of the Lap-Band surgery include:
     a. Risks that apply to all major surgeries.
     b. Staple leaks.
     c. Severe nutrit ional deficiencies.
     d. Possible band removal.
     e. A and D.

6.   Lap-Band System surgery is always performed lapraoscopically.
     a. True
     b. False



                                                                  5
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
7.   What food is recommended immediately after surgery? (circle all that apply)
     a.   Solid food.
     b.   Broth.
     c.   Liquid and soft food.
     d.   Sucking on ice cubes.
     e.   Don’t know/ Not sure.

8.   Weight loss soon after surgery varies considerably for most patients. Which of the following will help you get
     started? (circle all that apply)
     a.   Following your doctor’s nutrition advice.
     b.   Following ―10 Important Rules.‖
     c.   Routine fo llo w-up visits with your doctor.
     d.   A low-carb diet.
     e.   All of the above.

9.   How is the Lap-Band System ad justed?
     a.   During surgery.
     b.   Without surgery.
     c.   Using a fine needle to add or remove flu id via an access port beneath the skin.
     d.   A and C.
     e.   B and C.
     f.   I don’t know.

10. When is the first band adjustment usually done?
     a.   During surgery.
     b.   1 week after surgery.
     c.   4-6 weeks after surgery.
     d.   3 months after surgery.
     e.   6 months after surgery.

11. The timing of your first band adjustment will depend on:
     a.   Your weight loss.
     b.   How much fluid is in your band.
     c.   Your exercise routine.
     d.   The amount of food you can eat.
     e.   All of the above.

12. How much flu id needs to be in a Lap-Band for optimal results?
     a.   2 cc.
     b.   4 cc.
     c.   10 cc.
     d.   It differs fo r each patient.

13. How many Lap-Band adjustments are needed?
     a.   1 every month.
     b.   4 per year.
     c.   5 within the first 5 years.
     d.   It varies fro m patient to patient.

                                                                  6
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
14. Who can perform a Lap-Band adjustment?
     a.   A certified surgeon.
     b.   A certified nurse practitioner.
     c.   A registered nurse.
     d.   All of the above.


15. It is always necessary to use X-ray for ad justment.
    a. True.
    b. False.

16. When might it be necessary for an adjustment to be done in an X-ray depart ment rather than the doctor’s office?
    (circle all that apply)
     a.   The first few days after surgery.
     b.   Before a patient has lost a lot of weight.
     c.   To assist the person doing the adjustment in locating the access port.
     d.   To evaluate stomach pouch and stoma size.

17. In the long-term, so me of the ―10 Important Ru les‖ are: (circle all that apply)
    a. Eat slo wly and chew thoroughly.
    b. Eat 5 meals a day.
    c. Drink water with your food.
    d. Exercise at least 30 minutes a day.

18. Under what conditions after leav ing the hospital should the patient immediately call h is or her doctor? (circle
    all that apply) [Dr. Advice]
     a.   Severe pain.
     b.   Elevated pulse over 120 beats/minute.
     c.   Inability to swallow.
     d.   Any significant wound bleeding or vomiting of blood.
     e.   All of the above.

19. Gain ing weight prior to surgery is dangerous because it can: (circle all that apply) [Dr. advice]
     a.   En large the liver.
     b.   Increase surgical risk.
     c.   Extend the recovery period.
     d.   Increase the risk of nutritional deficiencies.

20. What are your weight loss expectations with the Lap-Band System? (circle all that apply)
     a.   Gradual and steady weight loss progression.
     b.   5 pounds a week during the first year.
     c.   1-2 pounds a week during the first year.
     d.   Losing 100% of my excess weight.

21. Losing weight too fast creates a health risk and can lead to a nu mber of p roblems.
     a. True.
     b. False.


                                                                  7
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Tax Deductible Medical Expenses for Obesity
According to CBS Market Watch, the cost of weight-loss programs — that are not part of the treatment for diseases,
such as obesity — are tax deductible. The Internal Revenue Service released this informat ion in March 2002.

The IRS stated, ―Obesity is med ically accepted to be a disease in its own right.‖

Taxpayers who participate in these programs for medically valid reasons will now be able to deduct amounts above
7.5 percent of their ad justed gross income, similar to any other medical expense not covered by insurance or other
reimbursement. A ta xpayer’s spouse and dependents would also be covered.

Still not deductible, however, are the costs of weight control programs intended ―to improve the taxpayer’s
appearance, general health and sense of well-being.‖

Diet foods are also not deductible, even though they are often an integral part of a weight control program under a
physician’s supervision. The IRS reasons that people have to pay for food whether or not they are trying to lose
weight.

Fees, diet menus and literature and other costs would be deductible.

The IRS specifically cited obesity and high blood pressure as examples of diseases for which the deduction could be
taken. But it would apply to any specific ailment diagnosed by a physician, including mental illness.

The ruling applies not only to current year tax returns, but goes all the way back to 1998. Taxpayers who want to
take the deduction need only file an amended return for the tax year in question.

The IRS also recently included smoking cessation programs as deductible medical exp enses, as are treatment and
other costs for alcoholism.

For more details go to www.IRS.gov and search in the Forms and Publications section under ―Obesity,‖ and consult
your Tax Advisor.




                                                                  8
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
                       For Primary Care Physician




The patient below is being evaluated for an adjustable gastric banding procedure (Lap-
Band), which is a weight reduction surgery. Below is a list of labs and documentation that
are needed for further evaluation. Please fax all information to the Wellborn Clinic as soon
as possible; 501.663.0465. We appreciate your referral.


Name                                                                                Date


Labs:

          CBC

          Co mprehensive metabolic profile

          Thyroid panel (T3, T4, and TSH)

          If d iabetic, hemag lobin a1c.

          30-minute post-prandial blood sugar (if not diabetic)

          Letter o f reco mmendation/ medical necessity from primary care doctor (insurance patients only)

          Two full years of clinical progress notes, for any reason, but especially docu menting obesity, weight
            loss attempts and co-morbidit ies. (Documented physician-supervised diets are very important for
            insurance approval. Check your insurance for exact requirements.)



Thank you for your help in th is matter. If you have any questions, please feel free to contact my office.



J. Clay Wellborn, Jr., M.D.
General and Bariatric Surgery




                                                                  9
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
                                            Sample Letter




Referring Physician: Please rewrite this letter on your letterhead and complete the
parenthesis fields with information specific to your patient, then fax the letter to the
Wellborn Clinic.




(Date)

Dr. James Clay Wellborn, Jr.
#1 St. Vincent Circle, Parkview Bldg #320
Little Rock, A R 72205

RE: (patient name)


Dear Dr. Wellborn:

(Patient’s name and age) has been under my care for ( __ ) years. (He/She) suffers fro m morbid obesity comp licated
by associated co-morb idit ies (obstructive sleep apnea, hypertension, NIDDM/IDDM, hyperlipidemia,
hypercholesterolemia, degenerative arthritis, GERD, stress incontinence, cardiorespiratory insufficiency,
Pickwickian Syndrome).

Due to weight, these conditions are becoming progressively less manageable or unmanageable through medicine
alone. The patient has tried numerous times to lose weight on my reco mmendation without any success for the last
( __ ) years. Methods include: (diets, exercise programs where appropriate, pharmacotherapy – please document
dates and methods, especially recent [six-months to one-year] efforts. Please list on the back of this letter or on a
separate form as this will help with insurance approval).

It is my opin ion that weight loss surgery is med ically necessary as the only option to effectively treat (his/her)
morb id obesity and its associated co-morbid ities, which cannot be effectively managed without weight reduction.

Sincerely,




(Physician’s name)




                                                                  10
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Medical Information Disclosure Notice
This notice describes how your medical information may be used and disclosed, and how
you can access this information. Please review it carefully.



Uses and Disclosure
Our practice collects personal health informat ion about you that may be used for four primary purposes:
         Treatment
         For examp le, we will prepare a record of informat ion each time we see you in or out of the office while you
         are under our care. Th is medical record is used to keep tract of changes in your condition as well as remind
         us of your past care, treatment, allergies and other facts relevant to your overall health. This informat ion
         may be passed on to other providers as part of coordinated health care program for you.
         Payment
         We must report elements of your personal health information — such as specific treat ments visits, tests and
         surgeries — along with related diagnosis to third-party payers so they may properly determine benefits
         payable on your behalf for our services. We only report the min imu m necessary information to process the
         claim.
         Health Care Operations
         In order to provide you with high-quality health care, we often need to be able to use your personal health
         informat ion for purposes such as pre-registering you at the hospital. Again, we are co mmitted to using the
         minimu m necessary information to achieve these purposes.
         BOLD: Bariatric Outcomes Longitudina l Data base
         A research study being conducted by East Caro lina University and Surg ical Rev iew Corporat ion. The
         study is about bariatric (weight loss) surgery. Before ag reeing it is impo rtant that you read and understand
         the available informat ion. Taking part in the research study is voluntary. If you decide not to take part in
         the study you will not be penalized or lose any benefits. You can still have surgery. You may stop taking
         part of the study at any time with a written request without penalty. A copy of full d isclosure is available at
         your request. Your signature on the following page signifies your agreement.

          In addition, we will use or disclose your personal health informat ion under the following circu mstances:

                   When we receive a valid authorization fro m you
                   If you give us an oral authorization



Required Disclosures
We are required to disclose the informat ion to you if you request it and we are required to disclose the information
to the US DHHS for co mp liance determinations of this practice. We may disclose informat ion about you without
your authorizat ion for the fo llowing reasons:

         When required by law, for judicial proceedings or law enforcement
         When required by law for public health agencies
         For wo rkers compensation
         For uses and disclosures about descendents
         Uses and disclosures for cadaver tissue donation
         To avert a serious threat to public health or safety
         For disclosures about abuse or neglect or domestic violence




                                                                  11
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Patient Consent for Use & Disclosure
of Protected Health Information
In signing this form, you consent to the use and disclosure of your protected health information by Dr. James C.
Wellborn, Jr., our staff, and our business associates strictly for the purpose of treatment, pay ment, research and
health care operations.

You acknowledge you have had an opportunity to review our Notice of Pri vacy Practices prior to signing this
consent form. We encourage you to review our Notice of Pri vacy Practices carefully . It provides more detail on
how we may use and disclose your information. The Notice of Pri vacy Practices is subject to change without
notice. A current copy may be requested when you are being seen as a patient or by contacting our manager at 501 -
663-9600 ext. 106.

You may request that we restrict how we use and disclose your protected health informat ion for the purposes
mentioned above. If you would like to request a restriction, please do so in writ ing. Ho wever, we reserve the right to
deny your request. If we grant your request, we are bound by the terms of the agreement.

You may also revoke this consent in writ ing. Ho wever, informat ion on any treatment of service provided using this
or prior consents may still be used or disclosed for purposes of treatment, pay ment or health care operations. Refer
to the Notice of Pri vacy Practices for further informat ion.

By signing this form, I grant consent to medical practice use and disclose my protected health information for the
purposes of treatment, pay ment and health care operations.

Signature of Pat ient or Decision Maker                                                       Date

Relationship to Patient/Legal Authority (if applicable)

Signature of Physician                                                                        Date

Witness                                                                                       Date

          AUTHORIZATION FOR RELEASE OF INDIVIDUAL IDENTIFIABLE HEALTH
                      INFORMATION TO DESIGNATED PARTY

This form releases the authorizat ion for a family member of your choice to have access to the following informat ion:
         This authorization grants permission to the designated party to:
I, ______________________________________, authorize permission to the designated party to:
     (print your name)
                   _____have access to my medical records, including test results
                   _____have access to my billing information
                   _____make and confirm appointments
                   _____other, please specify ________________________________________.
I understand this authorization will be effective fo r the lifet ime of the patient unless revoked in writ ing. I
understand that my treat ment cannot be conditioned on whether I sign this authorization.

Person Authorized to Share your informat ion:_________________ _____________________________________

_____________________________________________________                              _________________________________
Signature of Pat ient or Representative                                            Date




                                                                  12
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Important Information
Office Address
#1 St. Vincent Circle, Suite 320
Parkview Building
Little Rock, A R 72205

Driving Instructions
Take 630 and exit on University Avenue.
Go North, take a right at St. Vincent Circle
This is about 1 block north of 630, your first right turn.
Go up hill past the first build ing on the right (this is the Parkview building) and enter driveway immed iately
past the building. Parking in the rear. Enter building and take elevator to suite 320, last door on the left.

Wellborn Clinic Hours
Monday and Wednesday, 9 a.m. to 5 p.m.
Tuesday, 1:30 p.m.-5:00 p.m..

Phone Numbers
Office: 501.663.9600
Fax: 501.663.0465
Please understand that our office phone call volu me is very high. We try hard to return calls in a t imely manner.
However, on occasion, it can take up to 24 hours to return non -emergency calls. Please be patient and do not
place more than one (1) phone call per 24 hours on our system. By working together we can manage the calls
more efficiently and answer patients’ questions more quickly. Feel free to e-mail us for appointments or for
other questions or comments.


Office Staff
Suzan, ext. 106; suzan@arkansasobesitysurgery.com (never hesitate to email me directly with any questions)
For nursing, financial or business questions.

Leslie, ext. 108; Leslie@arkansasobesitysurgery.com
Surgery and procedure scheduling, and self pay patients (Leslie is a lapband patient).

Jamie, ext. 111; Jamie@arkansasobesiysurgery.com
For prior approvals or insurance questions and support group questions (Jamie is a lapband patient).

Nicole, ext. 110; n icole@arkansasobesitysurgery.com
For self pay and general questions (Nicole is a lapband patient).

Lee, ext 100: lee@arkansasobesitysurgery.com
For scheduling and general questions (Lee is a lapband patient)


Web Site
www.drclaywellborn.com or www.arkansasobesitysurgery.com




                                                                  13
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Emergency Information
If you have a medical emergency, do not hesitate to DIAL 91 1.
For after-hours emergencies, Dr. Wellborn can be reached by calling the Medical Exchange at (501) 663 -8400.
If at all possible, please try to limit your calls to office hours. By doing so, we can handle true after-hour
emergencies more efficiently.



Prescription Refills or Appointments
If you need a refill or appointment, p lease do not wait until the last minute. Please remember Dr. Wellborn is
NOT in the Clin ic Tuesday mornings, or all day on Thursdays and Fridays. If you know you are in need of a
refill or an appointment please call (501) 663-9600 ext 106 or email suzan@arkansasobesitysurgery.com and
leave all pert inent informat ion. We will schedule or call-in prescriptions and call you back as soon as possible.
Please allow 24 hours on all pres criptions.



Lap-Band Fills
Fills are done in the office according to need. We try to schedule all in-o ffice fills on Monday, Tuesday and
Wednesday afternoons. Please keep this in mind when coordinating fill (and unfill) scheduling. We
occasionally will do Saturdays. Stay on our email list to keep updated. You can email
Jamie@arkansasobesitysurgery.com to get on the list. We also have a facebook page: The Wellborn Clinic,
there is a link on our home page.




                                                                  14
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • phone 501 .663 .9600 • fax 501 .663 .04 65
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
 INFORMED CONSENT FOR GASTRIC LAPBAND PROCEDURE




It is very important to your doctor that you understand and consent to the treatment your doctor is rendering and any
treatment your doctor may perform. You should be involved in any and all decisions concerning surgical
procedures, which you may need to have. Sign this form only after you understand the procedure, the risks, the
alternatives, and the risk associated with the alternatives and after all o f your questions have been answered. Please
initial and date direct ly below this paragraph indicating your understanding of this paragraph.

____________________________________________ _________________________________
Patient’s init ials or Authorized Representative Date

I have reviewed drawings of each of the available Bariat ric operations that diagrammatically show the main
characteristics of each type of weight reduction operations, differences among operations, advantages, and
disadvantages, of each procedure. I have had a chance to express to the surgeon my eating habits and behavior and
my medical history and the surgeon has helped me to personally come to a conclusion as to the most appropriate
operation for me, factoring in my eating, d ietary, and medical backg round, and my future weight loss goals,
pregnancy plans, and personal limits regarding acceptable meal size, bowel habits, and risk tolerance. The surgeon
has counseled me regarding my decision, has made professional reco mmendat ions, and we have together agreed on
the planned procedure as acceptable and appropriate.

_________________________________________                         __________________________________
Patient’s Initials or Authorized Representative                    Date

I, _______________________________________, hereby authorize Dr. Wellborn and any associates or assistants
the doctor deems appropriate, to perform gastric lapband surgery.

The doctor has exp lained to me the risks of obesity and the benefits of a gastric lapba nd procedure. However, I
understand there is no certainty that I will achieve these benefits and no guarantee has been made to me regard ing
the outcome of the procedure. I also authorize the admin istration of sedation and/or anesthesia as may be deemed
advisable or necessary for comfort, well being and safety.

Conditi on. I recognize that I am severely overweight with a weight of_________lbs at_____ft.___inches tall. I
understand that if my BMI is less than 40, and I have other co-morbidit ies, I may be a candidate for this surgery, as
explained by my physician. My surgeon or surgeons have clearly exp lained to me that this level of obesity has been
shown to be unhealthy and that many scientific studies show that persons of this level of obesity are at in creased
risks of respiratory disease, high blood pressure, heart disease, high cholesterol, stroke, diabetes, arthrit is, clotting
problems, cancer and death as well as other serious and less serious medical illnesses.

COMMIT MENT I am co mmitted to long-term follow-up with my surgeon or surgeons and to make every effort to
follow h is/her directions to protect myself fro m these and other problems associated with Gastric Banding. I
understand that to be effective, I need to make a life -long commit ment to lifestyle changes, which may include, but
not be limited to, dietary changes, an exercise program, and counseling. I understand that I will need to maintain
proper nutrition, eat a balanced diet, and take v itamin and mineral supplements for the rest of my life. I will also be

                                                                  15
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
required to maintain follow-up medical care for my lifetime. Laboratory work will be required at least annually, and
perhaps more often, as directed by a physician.

PRE-OPERATIVE REQUIR EMENTS I agree to participate in a post-surgical mult idisciplinary program that
includes diet, physical activity, and behavior modification.

POST-OPERATIVE REQUIREMENTS I agree to participate in a post-surgical mu ltidiscip linary program that
includes diet, physical activity, and behavior modification.

PROPOS ED PROCEDURE I understand that the procedure that my surgeon or surgeons have recommended for
the treatment of my obesity is the gastric lapband procedure. I have been strongly encouraged to make every effort
to investigate and understand the details of the operation.

I understand the nature of a gastric lapband procedure, which will be done laparoscopically. I understand that
performing this procedure laparoscopically entails the use of a fiberoptic endoscope along with special endoscopic
instruments and staplers to facilitate in co mpleting the procedure with smaller incisions than in an open approach. I
understand that it may be necessary to convert the procedure to an open technique if it is felt to be the best
med ical/surgical decision in the judg ment of my surgeon (s). This conversion will result in a larger incision, which
has been described to me by my surgeon.

CONTRAINDICATIONS contraindications include, but are not limited to: current inflammatory disease or
condition of the gastrointestinal tract such as ulcers, sever esophagitis, or Crohn’s disease; current severe heart or
lung disease which may make me a poor candidate for surgery; other disease that makes me a poor candidate for
surgery; current health condition which causes bleeding in the esophagus or stomach, which might include
esophageal or gastric varices (a dilated vein) or a congenital or acquired intestinal telangiectasia (dilation of a small
blood vessel); current portal hypertension; an abnormal esophagus, stomach, or intestine whether congenital or
acquired), such as a narrowed opening; prior intra-operative gastric injury such as a gastric perforat ion at or near the
location of the intended band placement, current cirrhosis, chronic pancreatitis, pregnancy, addiction to alcohol or
drugs; an infection anywhere in my body, one that could contaminate the surgical area; chronic, long -term steroid
treatment; inability to fo llo w the dietary rules that come with this procedure; allergy to materials in the device;
autoimmune connective tissue of my own or so meone in my family, such as systemic lupus erythematosus or
scleroderma, or sy mptoms of one of these types of disease. In addition, patients with a ―sweet tooth‖ will not do
well with the gastric lapband procedure or those that often drink milk shakes or other high-calorie liquids.

RIS KS/POSSIBLE COMPLICATIONS The doctor has explained to me that there are risks and possible
undesirable consequences associated with any surgery, as well as risks and possible undesirable cons equences
associated with the lapband procedure and these include, but are not limited to: death; gastric perforation (a tear in
the stomach wall) during or after the procedure that might lead to the need for another surgery; hospitalizat ion
and/or re-operation; nausea/vomiting; gastroesophageal reflu x (regurgitation); band slippage/pouch dilation; stoma
obstruction (stomach-band outlet blockage); esophageal dilatation or dysmotility (poor esophageal function) which
can be caused by improper p lacement of the band, the band being tightened too much, stoma obstruction, binge
eating, or excessive vomiting; constipation; diarrhea; dysphagia (difficulty swallo wing); re -operation to fix a
problem with the band or init ial surgery or to fix a leak or twisted access port; band erosion into the stomach; band
removal in a second operation, esophagitis (inflammat ion to the esophagus), gastritis (inflammation of the
stomach)), hiatal hernia, incisional hern ia, infection, redundant skin, dehydration, diarrhea (frequent semi-solid
bowel movements), abnormal stools, constipation, flatulence (gas), dyspepsia (upset stomach), eructation
9belching), cardiospasm (an obstruction of passage of food through the bottom of the esophagus), hematemesis
(vomiting of b lood), asthenia (fatigue), fever, chest pain, incision pain, contact dermat itis (rash), abnormal healing,
edema (swelling), paresthsia 9abnormal sensation of burning, prickly, or t ingling), dysmenorrhea (d ifficu lt periods),
hypochromic anemia (low o xygen carrying part of b lood), band system leak, cholecystitis (gall stones), esophageal
ulcer sore), port d isplacement, port site pain, spleen injury, wound infection, u lceration, gastroesophageal reflu x
(regurgitation), heartburn, gas bloat, dehydration, regaining of weight, slow weight loss or none at all, anemia,
vitamin deficiencies and malnutrition.



                                                                  16
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Laparoscopic surgery has its own potential risks and complications, wh ich include but are not limited to spleen or
lever damage (somet imes requiring spleen removal), damage to ma jor blood vessels, lung problems, thrombosis
(blood clots), rupture of the wound, and perforation of the stomach or esophagus during surgery. Laparoscopic
surgery is not always possible, and the surgeon may need to switch to an ―open‖ method due to some o f the reasons
mentioned here.

Risks and possible co mplications are also associated with the lapband procedure, which include but are not limited
to the band can spontaneously deflate because of leakage (which can co me fro m the band, the reservoir, or the
tubing that connects them), the band can slip, there can be stomach slippage, the stomach pouch twisting, or stomach
pouch enlargement), and the band can erode into the stomach.

Further, and of these risks or co mplications may require further surgical int ervention during or after the procedure,
which I expressly authorize.

I also understand that some or all o f the comp lications listed on this form and also exp lained to me may exist
whether the surgery is performed o r not, in that gastric lapband surgery is not the only cause of these complications.

I understand that women of childbearing age should avoid pregnancy until their weight becomes stable because
rapid weight loss and nutritional deficiencies can harm a developing fetus.

ALTERNATIVE PROCEDUR ES In permitting my doctor to perform this procedure, I understand that unforeseen
conditions may necessitate change or extension of the orig inal procedure(s), including co mplet ing the operation by
way of the conventional open surgical approach, or a diffe rent procedure fro m what was explained to me. I
therefore authorize and request that Dr. James Clay Wellborn, h is assistants or designees to perform such
procedure(s) as may be necessary and desirable in the exercise of his professional judgment.

The reasonable alternative(s) to the procedure(s) as well as the risks to the alternatives have been exp lained to me.
These alternatives include, but are not limited to, various diets and weight reducing plans with or without the use of
med ications, exercise regimens, psychological or psychiatric therapy, an other regiments, gastric bypass surgery,
and various diet exercise and drug treatments.

I hereby authorize the disposal of removed tissues resulting from the procedure(s) authorized above.

I consent to the photographing or videotaping of the procedure(s) that may be performed, provided that my identity
is not revealed by the pictures or by descriptive text acco mpanying them.

By signing below, I certify that I have had an opportunity to ask the doctor all questions concerning risks,
alternatives, and risks of those alternatives.

___________ ______________                     _____________________________ _________________
Date         Time                                  Signature of Patient          Relationship of
                                                   Or Authorized Representative  Authorized Rep
WITNESS:

_____The patient/Authorized Representative has read the form or had it read to him/her.
_____The Patient/Authorized Representative expresses understanding of the form
_____The Patient/Authorized Representative has no questions


___________         ________________                      ________________________________________
Date                 Time                                 Signature of Witness




                                                                  17
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
                                   CERTIFICATION OF THE PHYSICIAN:

I hereby certify that I have discussed and explained the facts, risks, the risks associated with the
alternatives of the procedure(s) described in this Consent form with the individual granting
consent.

_____________ ______________
________________________________________________
Date            Time            Signature of Physician




USE OF INTERPRETER OR SPECIAL ASSISTANCE

An interpreter or special assistance was used to assist patient in completing this form as follows:

______Foreign Language

______Sign language

______Patient is blind, form read to patient

______Other (specify)_______________________________________________________

Interpretation provided by:____________________________________________________
                           Fill in name of Interpreter and Title or Relationship to Patient

______________________________________                               ____________             ____________________
Signature (Individual Providing Assistance)                            Date                   Time




                                                                  18
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Insurance Information
Insurance is strange regarding coverage of weight reduction surgeries. In general things to look for in
your policy are exclusions and benefit limitations for weight loss surgery. Some plans— particularly
HMO’s, exclude obesity surgeries even in patients with life threatening disorders, and they make
NO exceptions. Usually in these cases— even with help from an attorney—it is nearly impossible to
deal with policies that have exclusions regarding the treatment of obesity, even if it is a clear-cut case of
medical necessity.

The most important aspect of the prior authorization process is to know and understand your individual
insurance policy. You must check to ensure there are no exclusions, and to determine the criteria for
medical necessity. In general, our office can assist you with the determination of medical necessity as
well as file the documentation required for prior authorization and pre-certification. Please understand
that insurance companies require both in some situations and that these two things are NOT the same.

Please realize that the process to get your surgery approved (any insurance) takes time. Do not expect
your surgery to be scheduled within the month you were seen in consultation. The Wellborn Clinic
normally schedules four to six weeks out. If there are cancellations in the schedule, we will call those
patients who have already received their prior approval to let them know of the available earlier option.
We will not begin the prior authorization process until all information needed is in our office, and / or we
have seen you in consultation.

Please understand that this is a time-consuming process. If we work together we can make a smooth
transition toward our goal. If you must check on your approval process, please call your insurance
company before calling us. We will call you when we have a determination in our office. Please try to
limit phone calls (for scheduling information or approvals) to once a week. E-mail us at any time and we
will get back to you as quickly as possible.

Due to the increasingly difficult and time-consuming process of getting your approval from your
insurance company, there is now a $275 insurance processing fee. This fee must accompany your patient
packet when you submit it. If you fax your packet, we can contact you for credit card information. This
is a non-refundable fee. It does remain your responsibility to contact your insurance company and
complete the questionnaire in the packet. All your required insurance criteria will still need to be
provided to us by you. We will assist you as much as possible in obtaining your approval. This fee
applies if you are in-network or out-of-network. If you are approved, this fee will apply to your initial
office visit. If you are denied, please understand there is no refund. If we process your insurance and the
insurance responds that there is an exclusion in your policy, there is still no refund.



Thank you so much for working with us.


Leslie, leslie@arkansasobesitysurgery.com
Lee, lee@arkansasobesitysurgery.com
Jamie, jamie@arkansasobesitysurgery.com
Nicole, nicole@arkansasobesitysurgery.com



                                                                  19
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Insurance Questionnaire
Important! Please use this form when calling your insurance company. Ask ALL questions
and fill in all spaces as you talk with your insurance care specialist. Return this form to us
with your patient information and obesity data. This way we all know what you need in
order to get your surgery considered for coverage.


Name

Insurance Company

Insurance Company Phone Nu mber I Called

Name of the Customer Serv ice Representative

Call Back Nu mber for Customer Serv ice Representative


Questions I Need to Ask:
1. Is there an exclusion for morb id obesity in my insurance policy?

2. Is morb id obesity (dx code: 278.01) a covered benefit in my policy?

3. What is my benefit level for the treat ment of morb id obesity up to and including surgery. (Is it 80/ 20? 60/40?)
   In network benefit level ______________________________________________________________________
   Out of network benefit level ___________________________________________________________________

4. Is CPT CODE 43770 for Lap-Band surgery a covered benefit?

5. Is CPT CODE 43846 for Gastric Bypass surgery a covered benefit? __________________________

6. Is Dr. James Clay Wellborn Jr. a covered specialist in your insurance network?

7. What hospital do I need to go to for surgery?

8. What criteria must be met for approval?

9. Do I need a psychiatric evaluation?

10. Do I need a d ietary consultation prior to final approval?

11. Do I need chart notes of supervised dietary attempts and a letter fro m the physician who fo llo wed me?
    (How many, how recent and how long must the attempts be?)


12. Is there any other information I haven’t mentioned that the insurance company is going to need?

13. What is the fax nu mber to where the medical docu mentation is to be sent for prior authorization?
 (Fax nu mber is MANDATORY!) ____________________________________________________ ____________




                                                                  20
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Patient Profile
Please print all information and provide as much detail as possible. We do not accept any
incomplete forms.
Personal Information
Last Name                                                                                     Date

First Name                                                                          M iddle Initial

Date of Birth                                       Social Security #                                                        ________

Race (check one)  White  African American  American Indian  Pacific Islander  Hispanic Other
Marital S tatus (check one)  M arried  Single  Divorced  Widowed  Partnered
Occupation (check one)  Time 
                           Full       Part Time Retired Self-Employed Homemaker Student Disabled Unemployed

Home Address

City                                                           State                           Zip Code

Telephone                                                      Cell Phone

Employer
                                                               Home
Business Phone                                                 E-mail
Contact Persons
Spouse                                              Social Security #____________________Date of Birth___________________

Street Address

City                                                           State                           Zip Code

Telephone                                                      Cell Phone

Business Phone                                                 E-mail


Emergency Contact ______________________________ Relationship                                                                ________

Street Address

City                                                           State                           Zip Code

Telephone                                                      Cell Phone

Business Phone                                                 E-mail
Pharmacy (information is mandatory)
Name___________________________________________________________________________________________________

Street Address

City                                                           State                           Zip Code

Telephone                                                Fax
How did you hear about out program? M D      TV Radio Word of M outh  Newspaper Internet Patient Referral
If Patient Referral, who can we thank? ________________________________________________________________________


                                                                  21
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Referral Information
Primary Care Physician

Street Address

City                                                           State                           Zip Code

Telephone

Fax

E-mail

S pecialty Physician                                                                                                         ________

Street Address

City                                                           State                          Zip Code

Telephone                                                      Fax

E-mail
Insurance Information
Primary Insurance Company                                                                                                    ________

Street Address

City                                                  State                                    Zip Code

Telephone

Subscriber’s Name

Subscriber’s Social Security #___________________________________________Date of Birth__________________________

Policy I.D. #                                                                            Group I.D. #

Secondary Insurance Company                                                                                       _______________

Street Address

City                                                  State                                    Zip Code

Telephone

Subscriber’s Name                                                             Date of Birth

Policy I.D. #                                                                            Group I.D. #

I hereby assign insurance benefits to Dr. J. Clay Wellborn. I understand that I am financially responsible for any charges that are
NOT covered by insurance. Should the account become delinquent, I understand that I am responsible for all finance charges,
legal fees, court costs and collection agency fees charged as a result of any collection activity. I hereby authorize Dr. Wellborn to
release my medical records or other information needed for my medical information.


Signed                                                                    Date
                                           Co-Pay must be pai d at ti me of service.


                                                                  22
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Out of Network Information
          Please be aware that Dr Wellborn is out of network with several insurance companies. We would still like
to be considered your surgeon for this surgery. We will work with you and your insurance to get you the best
med ical care possible. We believe that even though you will have some cos t at the beginning of surgery, you will
not regret using our clinic. We have very good patient weight loss statistics, 10%-15% better than the national
average. We also have four successful lap band patients that work in th e office, who have lost nearly 700 pounds all
together! They are your support group and cheerleaders! They have walked in your shoes, and know exactly what
you are going to go through. That kind of experience and success is Priceless!
          Out of network benefits work as follows. Our fee is $4500, and must be paid up front. The fee covers not
just your surgery, but, all of your adjustments for the next 18 months. This is only for self-pay or out of network
patients. Most insurance’s only cover adjustments for the first 90 days. As adjustments are $100 each, you could be
saving over $1500 if you have just one adjustment a month for the next year and a half! Most patients have
between 6-12 fills in the first year.
          We will work with you to get you pre-approved by your insurance, and your hospital is still in network.
We will also bill your insurance company for the initial v isit/processing fee of $275, as well as for the surgery
$4500. If you have out of network benefits available, then your insurance will reimbu rse you directly.
          We will also bill your insurance for each ad justment for the next 18 months, or provide you a form that you
can send to your insurance company to get reimbursed for the adjustment. You will be required to remit any in
network deductible and out of pocket amounts to the hospital, if you have any due, prior to your surgery. Please
contact Leslie at ext. 108, or Jamie at ext. 111 if you have any questions.


Financing Information
                                Self pay surgery price appro ximately $16,000(can vary)
Listed below are some financing options. We provide these names and phone numbers as a service only. Please
note: WE DO NOT ENDORS E OR RECOMMEND any one in particu lar. There are many financing options
available, please don’t hesitate to exp lore all of them. Good Luck!

Care Credit - (total cost $16,275.00 w/fees)
1-800-839-9078
www.carecredit.co m

HealthOne Financing – (total cost $16,000)
Dr. ID 14121
1-888-748-3621
www.healthone-financial.com/applicationhtm

Esolutions Medical Financing -($16,275.00 w/fees)
1-800-728-9585
info@efinancing-solutions.com

Med Prova Patient Funding ($16,275.00 w/fees)
1-888-444-0016
info@medprova.com


  PLEASE NOTE!!! THERE MAY BE ADDITIONAL CHARGES TO YOU BY
          THE WELLBORN CLINIC FOR PROCESSING FEES
           All prices subject to change with out notice.




                                                                  23
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
                                  History and Physical




Please complete the form with as much detail as possible. We will return incomplete forms.


Name                                                                      Date

Height                                                                    Weight



Weight Loss History
Please fill in the blanks and check the appropriate boxes below.
   Volume Eater
          I consume larger a mounts of food, especially foods I enjoy. I enjoy sweets as well but only snack or stress -
          eat occasionally.
     Sweets-Eater
       I prefer foods high in sugar (i.e. candy, cookies, etc.) I will eat less of normal food to save room for sweets.
       I drink non-diet beverages or sweetened liquids as well. I eat snack and stress -foods predominantly high in
       sugar.
    Snacker
       I don’t eat regular meals. I frequently eat fast food and select foods high in calories (high fat and high -
       carb). I eat between meals and I am not generally hungry at meals. I am seen to be constantly ―grasping‖
       for food.

How long have you been at your present weight? ______________ What did you weigh 5 years ago? __________




                                                                  24
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Weight Loss Programs:                                          Please check all the weight l oss programs/methods that
  you have tried in the past.

 1200 Calorie Diet                                 Acupuncture                             Aerobic Classes
 A mphetamines                                     Atkins                                  Body Solutions
 Cabbage Soup                                      Calorie Counting                        Camb ridge
 Christian Based                                   Curves for Wo men                       Cutting back portions
 Dexatrim – no M D                                 Diabetic Diet                           Diet Pills
 Diet Center                                       Diet Patch                              Dietician
 Exercise                                          Fat Burner                              Grapefruit Diet
 Green Tea                                         Health Club/ Gy m                       Heart Smart Diet
 Herbal Life                                       High Protein                            Hollywood Diet
 Hypnosis                                          Jenny Craig                             LA Weight Loss
 Lean Cuisine                                      Life Steps                              Lo w Calories Diet
 Low Carb Diet                                     Lo w Fat Diet                           Mayo Clinic
 MD Opti-fast                                      MD Supervised Diet                      Merid ia
 Metabolife                                        Nutri-Systems                           Opti-fast
Other _________________________                    Overeaters Anonymous                    Phen-fen
 Pondimin                                          Prism                                   Psychotherapy
 Redu x                                            Relacore                                Rice Diet
 Richard Simmons                                   Scarsdale                               Slim Fast
 South Beach Diet                                  Stacker 2                               Starvation Diet
 Subliminal Tapes                                  Subway Diet                             Sugar Busters
 Susan Powers                                      TOPS Diet                               Trim Spa
 VCR Tapes                                         Weight Loss Clinic                      Weight Watchers
 Xenadrine                                         Xenical – M D                           Zantrex – 3
 Zenadrine                                         Zenical 70                              Zone




                                                                  25
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Co-Morbidities
Check the appropriate responses for any co- morbidities you have.



Diabetes:                                                                Arthritis:
     □    Borderline or chemical                                              □Pain ful and/or swollen jo ints
     □    Controlled with oral medication                                     □Ankles
     □    Poorly controlled                                                   □Knees
     □    Gestational                                                         □Hips
Hypertension:                                                                 □Back
     □Borderline                                                             □Neck
     □Controlled with med ication                                            □Feet
     □Poorly controlled                                                      □Shoulders
     □Progressively more difficult to control                                □Rheu matoid
Hypercholesterlemia:                                                          □Post-Traumat ic
     □Borderline, but not on medication                                      □Degenerative (osteoarthritis)
     □Controlled with med ication                                       Degenerative Arthritis:
     □Poorly controlled                                                      □
                                                                                Progressively worsening
     □Progressively more difficult to control                                □Taking medications
Hyperlipidemia:                                                               □Prev ious surgery
     □Borderline, but not on medication                                      □Need surgery, but must lose weight first
     □Controlled with med ication                                       Obstructive Sleep Apnea:
     □Poorly controlled                                                      □On CPAP/ BiPAP
     □Progressively more difficult to control                           Poly-Cystic Ovarian Syndrome:
Esophageal Reflux (GERD):                                                     □Infert ility
     □Borderline, occasionally if I overeat                                  □Irregular Periods
     □Controlled with med ication                                       Stress Incontinence:
     □Poorly controlled                                                      □Yes
     □Progressively more difficult to control                                □No
Asthma:                                                                  Heart Disease related to weight:
     □Borderline as a child, but not since                                   □Yes
     □Controlled with med ication                                            □No
     □Poorly controlled                                                 I have or have been observed to:
     □Progressively more difficult to control                                □Snore
Congestive Heart Failure:                                                     □Awaken easily
     □Controlled with med ication                                            □Have viv id dreams
     □Poorly controlled                                                      □Have a hard t ime staying up past 8 p.m
     □Progressively more difficult to control                                □Fall asleep in mid-afternoon
                                                                              □Wake up feeling unrested
                                                                              □Breath funny, or stop breathing while asleep




                                                                  26
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Exercise
Check the boxes below that reflect the amount of exercise you do for each activity.

I walk:                                                                  I do aerobics:
     Daily                                                                  Daily
     3-4 t imes/week                                                        3-4 t imes/week
     1-2 t imes/week                                                        1-2 t imes/week
     Rarely                                                                 Rarely
     Never                                                                  Never

I bicycle:                                                               I lift weights:
     Daily                                                                  Daily
     3-4 t imes/week                                                        3-4 t imes/week
     1-2 t imes/week                                                        1-2 t imes/week
     Rarely                                                                 Rarely
     Never                                                                  Never

I swim:                                                                  I engage in                                         :
     Daily                                                                  Daily
     3-4 t imes/week                                                        3-4 t imes/week
     1-2 t imes/week                                                        1-2 t imes/week
     Rarely                                                                  Rarely
     Never                                                                  Never




Family History
Fill in the spaces with the appropriate information. If family member is not living, please
indicate age at death.



 Medical Condition                       Father              Mothe r                     Siblings             Aunts/Uncles
 Diabetes
 Hypertension
 Early death from
 cardiovascular disease
 Stroke
 Heart attack
 Cancer
 Obesity
 Cardiovascular disease
 High cholesterol




                                                                  27
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Medications
Please list all medications you take that are not listed in the Weight Loss Medication chart.


                                                                                       Reason for                   How long
 Name of drug                     Dosage                   Frequency                     taking                      taking?

 Name of drug                     Dosage                    Frequency




Surgeries
Check and list all surgical procedures you have had i n your lifetime.

Tubal Ligation Date______________________                              Co lon Surgery    Date____________________
Tonsillecto my Date______________________                              Neck Surgery       Date____________________
Appendectomy Date______________________                                Joint Rep lacement Date___________________
Partial Hysterectomy Date_________________                             Cholecystectomy Date___________________
Back Su rgery Date______________________                               Caesarean Surgery Date___________________
Heart Bypass Date______________________                                Total Hysterectomy Date__________________
Arthroscopy Date______________________                                 Lap Cholecystectomy Date_________________


Other procedures




                                                                  28
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om
Allergies
Check all medications, food and other allergies you have.

Aspirin                                                                Demerol
Penicillin                                                             Hudrocodone
Keflex                                                                 Tape
Ibuprofen                                                              Latex
Tetracycline                                                           Shellfish
Erthro mycin                                                           Sulfa
Darvocette                                                             X-Ray dye
Codeine                                                                Betadine
Morphine
Other allergies




                                                                  29
T he Wellborn Clinic • #1 St. Vinc ent C ircle, Parkview Bldg #320 • L ittle Rock AR 72205 • ph one 501 .663 .9600 • fax 501 .663 .0465
               e- mail: info@ arkansas obesitysurgery.c om • web: drc laywellborn.com or arkans asobesitys urgery.c om

				
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Description: Financial Assistance for Lap Band Surgery document sample