VIEWS: 4 PAGES: 14 POSTED ON: 4/19/2011
Bariatric Patient History Questionnaire Demographics: Please fill out completely___________________________________________________________ First Name: Middle Name: ________ Last Name: Nickname/ preferred name: Maiden Name: Date of Birth: Gender: Male Female Marital Status: Single Married Divorced Separated Partnered Widowed Social Security Number: - - Ethnicity: African American Arabic Asian Caucasian Hispanic Native American Other Religious Affiliation: Patient Level of Education: Employment Status: Full-time Part-time Retired Disabled Housewife Student Unemployed If disabled, specify the year and the cause: Year: Cause: Patient Occupation (indicate if student): Patient Employer: Years Employed: Patient Employers Address: Reason for Visit (i.e. why are you seeking weight loss surgery?): List your preferred procedure: Referral Information: Please circle how you heard about TLC Surgery_________________________________ Internet/Facebook Magazine Newspaper Other Patient Our Website Television Yellow Pages Physician Referral: _____________________________ Hospital Referral: _____________________________ (name of physician) (name of hospital) Do you like to use Facebook? Yes No If yes, may we send you a friend request? (We hold monthly Support Groups via Facebook and also post valuable information for patients) Address Information: Please fill out all information completely_________________________________________ Street Address: City: State: Zip Code: Country: E-Mail: Phone (home): - - Is it ok to leave a message on this number? Y N Phone (work): - - Is it ok to leave a message on this number? Y N Phone (mobile): - - Is it ok to leave a message on this number? Y N Spouse Information: Please fill out all information completely_________________________________________ Spouse name: Spouse employment status: Full-time Part-time Retired Disabled Housewife Student Unemployed Spouse’s occupation (indicate if student): Spouse’s SSN: - - Spouse’s date of Birth: / / Spouse’s Employer: Years Employed: Emergency Contact #1:__________________________________________________________________________ First Name: Last Name: Relation to you: Phone: - - Emergency Contact #2: First Name: Last Name: Relation to you: Phone: - - Insurance Information: Please fill out all information________________________________________________ Insurance Company: Policy Number: Payment Type: Group Number: Full Name of Insured: Effective Date: / / Insured DOB: / / Terminated Date: / / Relationship to Insured: Insured Employer: SS# of Insured: - - Insured ID: Notes: Insurance Phone#: - - Weight-Loss History: Please fill out all information__________________________________________________ What is your height? Ft In How much do you weigh? Lbs From what age have you been obese? Years For how many years have you been at your current weight? Years What was your maximum adult weight? Lbs What was your minimum adult weight? Lbs What was the most weight you ever lost on a single diet? Lbs How many months did you keep it off? What was your weight at the following ages (estimate)? Age 10 Age 18 Age 25 Age 30 Age 35 Age 40 Age 45 Age 50 Age 60+ Please list all weight loss medication you have taken: _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________ Comorbidities: Please only select ONLY ONE per category for each system_______________________________ ***Please note that if you are not familiar with a listed condition, then it may not pertain to you! Cardiovascular System o No symptoms of peripheral vascular Hypertension: disease o No history o Asymptomatic with bruit o Borderline, no medication o Claudication, anti-ischemic o Diagnosis of hypertension, no medication medication o Treatment with single medication o Transient ischemic attack, rest pain o Treatment with multiple medications o Procedure for peripheral vascular disease Congestive Heart Failure: o No history or symptoms of congestive heart Lower Extremity Edema: failure o No symptoms of lower extremity o Class I: Symptoms with more than ordinary edema activity o Intermittent lower extremity edema, o Class II: Symptoms with ordinary activity does not require treatment o Class III: Symptoms with minimal activity o Symptoms requiring treatment, o Class IV: Symptoms at rest diuretics, elevation, or hose o Stasis ulcers Ischemic Heart Disease: o Disability, decreased function, o No history of ischemic heart disease hospitalization o Abnormal EKG, no active ischemia o PCI, CABG o Active ischemia Angina Assessment: o No chest pain symptoms/angina Peripheral Vascular Disease: o Anginal chest pain with extreme exertion, o History of DVT resolved with such as running, swimming, etc… anticoagulation o Anginal chest pain occurs with moderate o Recurrent DVT long term activity or exertion anticoagulation medication o Anginal chest pain with minimal exertion, o Previous PE such as walking across a room o Recurrent PE, decreased function, o Unstable angina hospitalization o Vena Cava filter Metabolic System Glucose Metabolism: o No symptoms of diabetes o Elevated fasting glucose o Diabetes, controlled with oral medication o Diabetes, controlled with insulin o Diabetes, controlled with insulin and oral medication Lipids: o Diabetes, with severe complications, such o Not present as retinopathy, neuropathy, renal failure, or o Present, no treatment required blindness o Controlled with lifestyle change, including Step 1 or Step 2 diet Gout/Hyperuricemia: o Controlled with single medication o No symptoms of gout/hyperuricemia o Controlled with multiple o Hyperuricemia, no symptoms medications o Hyperuricemia, medications o Not controlled o Arthropathy o Destructive joints o Disability, unable to walk Gastrointestinal System GERD: o No history of GERD o Intermittent or variable symptoms of GERD o Intermittent medication o H2 blockers or low dose PPI Liver Disease: o High dose PPI o No history of liver disease o Meet criteria for anti-reflux surgery, or o Hepatomegaly modest, normal prior surgery for GERD LFT’s, fatty change Category 1 Cholelithiasis: o Modest or greater hepatomegaly, o No history of gallstones LFT alteration, fatty change o Gallstones with no symptoms Category 2 o Gallstones with intermittent symptoms o Moderate to marked hepatomegaly, o Gallstones with severe symptoms or h/o fatty change Category 3, mild cholecystectomy inflammation, mild fibrosis o Gallstones with complications requiring o Definite NASH, cirrhosis, hepatic immediate surgery prior to this dysfunction by LFT’s o Cholecystectomy, with unresolved o Hepatic failure, transplant indicated complications or done DVT/PE: o No history of DVT/PE Musculoskeletal System Musculoskeletal Disease: o No symptoms of musculoskeletal disease o Pain with community ambulation o No symptoms of back pain o Non narcotic analgesia required o Intermittent symptoms not requiring o Pain with household ambulation medical treatment o Surgical intervention required o Degenerative changes or positive objective (arthroscopy) findings, symptoms requiring narcotic o Awaiting or past joint replacement or other treatment disability o Surgical intervention done or recommended pending weight loss Fibromyalgia: o Failed previous surgical intervention with o No history of fibromyalgia existing symptoms o Treatment with exercise o Treatment with non-narcotic medications o Treatment with narcotics o Treatment with narcotics, surgical intervention done or recommended o Disabling, treatment ineffective Menstrual Irregularities (not PCOS): Reproductive System o No history Polycystic Ovarian Syndrome (PCOS): o Irregular periods or oligomenorrhea o No history of PCOS o Menorrhagia o Symptoms of PCOS, no treatment o Amenorrhea o OCP’s or anti-androgen medications o Prior total abdominal hysterectomy o Medformin or TZD o Combination Therapy o Infertility Confirmed Mental Health Diagnosis: Psychosocial o None Psychosocial Impairment: o Bipolar Disorder o No impairment o Anxiety/Panic Disorder o Mild impairment in psychosocial functions, o Personality Disorder but able to perform primary tasks o Psychosis o Moderate impairment in psychosocial functions, but able to perform most Depression: primary tasks o No symptoms of depression o Moderate impairment in psychosocial o Mild and episodic not requiring functioning and unable to perform some treatment primary tasks o Moderate, accompanied by some o Severe impairment in psychosocial impairment, may require treatment functioning and unable to perform most o Moderate with significant primary tasks impairment, treatment indicated o Sever, definitely requiring intensive treatment o Severe, requiring hospitalization General Stress Urinary Incontinence: o No history of stress urinary incontinence o Minimal and intermittent o Frequent but not severe o Daily occurrence, requires sanitary pad Back Pain: o Disabling o Operating ineffective Pseudotumor Cerebri: o No symptoms of pseudotumor cerebri o Headaches with dizziness, nausea, and or pain behind the eyes Functional Status: o Headaches with visual symptoms and or o No impairment of functional status controlled with diuretics o Able to walk 200 ft with assistance device, o Had MRI to confirm PTC, is well controlled such as cane or crutch with oral diuretics o Cannot walk 200 ft with assistance device, o Patient is well controlled with stronger such as cane or crutch medications o Requires a wheelchair o Patient requires narcotics or has had, or o Bedridden needs surgical intervention Abdominal Skin/Pannus: Abdominal Hernia: o No symptoms o No hernia o Intertriginous irritation o Asymptomatic hernia, no prior operation o Pannus so large it interferes with o Symptomatic hernia with or without ambulation incarceration o Recurrent cellulitis, ulceration o Successful repair o Surgical treatment required o Recurrent hernia or size > 15 cm o Chronic evisceration through large hernia with associated complications or multiple failed hernia repairs Surgical/ Hospitalization History: Please circle all surgeries you have ever had in your life time____________ Month Year Gallbladder (Open): Y N Gallbladder (Laparoscopic) Y N Appendectomy: Y N Hysterectomy (Uterus removed- vaginal): Y N Hysterectomy (Uterus removed- abdominal): Y N Ovary Surgery: Y N Cesarean Section: Y N Back: Y N Right Knee: Y N Left Knee: Y N Right Breast Biopsy: Y N Left Breast Biopsy: Y N Previous Weight-Loss Surgery Y N Tonsillectomy: Y N Hernia: Y N Tubal Ligation: Y N Kidney Transplant: Y N Liver Transplant: Y N Pancreas Transplant: Y N Other 1: Other 2: Other 3: Social History: Please select all that apply_________________________________________________________ Alcohol Use: Tobacco Use: Substance Abuse (Rx or Illegal) o None o None o None o Rare o Rare o Rare o Occasional o Occasional o Occasional o Frequent o Frequent o Frequent Drinks per week: _______ Packs per week: _______ Usage per week: _______ Family history: Please circle all that apply_______________________________________________________ Obesity Y N # of family deaths related to obesity Kidney Disease Y N Heart Disease Y N Diabetes Mellitus Y N High blood pressure Y N Alcoholism Y N Liver problems Y N Lung problems Y N Bleeding disorder Y N Gallstones Y N Mental Illness Y N Cancer Y N Type: If another please specify type: Malignant hyperthermia Y N Adopted? Y N Drug Allergies: please list all DRUG allergies_____________________________________________________ Name of Medication Reaction it Causes 1. 2. 3. 4. 5. 6. Skin Allergies: please circle all SKIN allergies Circle all that apply Reaction it Causes 1. Latex___________________________________________________________________________ 2. Iodine___________________________________________________________________________ 3. Band-Aid Bandages or Adhesive______________________________________________________________ 4. Other:___________________________________________________________________________ Medications/Vitamins & Minerals: Please list all medication that you currently use______________________ Name Dosage Frequency* Indication 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. *Frequency: QD: 1x daily BID: 2x daily TID: 3x daily QID: 4x daily QOD: 1x daily, every other day Blood Analysis:____________________________________________________________________________ Have you ever received a blood transfusion? Y N Would you accept a blood transfusion? Y N Have you ever had hepatitis? Y N Have you ever been exposed to HIV/ AIDS? Y N Have you ever abused intravenous drugs? Y N Review of Systems: Circle all the health problems you have had or are currently experiencing___________ ***Please note that if you are not familiar with a listed condition, then it may not pertain to you! Cardiovascular:_______________________________________________________________________________ Heart Attack Y N Angina (chest pain with activity) Y N Rhythm disturbance/ palpitations Y N Congestive Heart Failure Y N High Blood Pressure Y N Ankle Swelling Y N Varicose Veins Y N Hemorrhoids Y N Phlebitis Y N Ankle/ leg ulcers Y N Heart bypass/valve replacement Y N Pacemaker Y N Clogged Heart Arteries Y N Rheumatic fever/ valve damage Y N Heart Murmur Y N Irregular heart beat Y N Cramping in legs when walking Y N Other Symptoms Y N Respiratory: ________________________________________________________________________________ Asthma Y N Emphysema Y N Bronchitis Y N Pneumonia Y N Chronic Cough Y N Short of Breath Y N Use of CPAP or oxygen supplement Y N Tuberculosis Y N Pulmonary Embolism Y N Hypoventilation Syndrome Y N Cough up blood Y N Snoring Y N Awaken at Night Y N Daytime Drowsiness Y N Sleep Apnea Y N Lung Surgery Y N Lung Cancer Y N Endocrine:___________________________________________________________________________________ Hypothyroid (low) Y N Hyperthyroid (high/ overactive) Y N Goiter Y N Parathyroid Y N Elevated Cholesterol Y N Elevated Triglycerides Y N Low Blood Sugar Y N Diabetes (Managed by diet pills) Y N Diabetes (Needing insulin shots) Y N “Prediabetes” w/ elevated blood sugar Y N Gout Y N Endocrine gland tumor Y N Cancer of endocrine gland Y N High Calcium level Y N Abnormal facial hair Y N Gastrointestinal:______________________________________________________________________________ Heartburn Y N Hiatal Hernia Y N Abdominal Hernia Y N Ulcers Y N Diarrhea Y N Blood in Stool Y N Change in bowel habit Y N Constipation Y N Irritable Bowel Y N Colitis Y N Crohn’s Y N Hemorrhoids Y N Fissure Y N Rectal Bleeding Y N Black, tarry stool Y N Polyps Y N Abdominal pain Y N Enlarged Liver Y N Cirrhosis/ hepatitis Y N Gallbladder problems Y N Jaundice Y N Pancreatic disease Y N Unusual vomiting Y N Surgery Y N Cancer Y N Bladder/ Kidney:______________________________________________________________________________ Kidney Stones Y N Blood in Urine Y N Prostate Problems Y N Kidney Failure Y N Leaking Urine Y N For men: PSA in last year? Y N Burning on Urine Y N Loss of bladder control (leakage) Y N Wear panty liner for leakage? Y N Trouble starting urine Y N Surgery Y N Cancer Y N Gynecologic (for women only):__________________________________________________________________ Problems conceiving (infertility) Y N Are you pregnant? Y N Uterine/ Ovarian Cancer Y N Surgery Y N Menstrual irregularity Y N Menstrual pain Y N Excessively heavy periods Y N Do you plan to have more children? Y N Abdominal pain Y N Date of menopause onset How many pregnancies have you had? Date of last pap-smear How many children do you have? Date of last Menstrual period Age started menses How many miscarriages or abortions have you had? Musculoskeletal:_______________________________________________________________________________Arthritis Y N Neck Pain Y N Shoulder Pain Y N Wrist Pain Y N Back Pain Y N Hip Pain Y N Knee Pain Y N Ankle Pain Y N Foot Pain Y N Heel Pain Y N Ball of foot/toe pain Y N Plantar fascitis Y N Carpal tunnel syndrome Y N Lupus Y N Scleroderma Y N Sciatica Y N Autoimmune disease Y N Muscle pain/spasm Y N Fibromyalgia Y N Broken Bones Y N Joint replacement Y N Nerve injury Y N Muscular dystrophy Y N Surgery Y N Cancer Y N Head And Neck:______________________________________________________________________________ Wear Contacts/ Glasses Y N Vision Problems Y N Hearing Problems Y N Sinus Drainage Y N Neck Lumps Y N Swallowing Difficulty Y N Dentures/ Partial Y N Oral Sores Y N Hoarseness Y N Head/ Neck Surgery Y N Cancer Y N Neurologic:___________________________________________________________________________________ Migraine Headaches Y N Balance Disturbance Y N Seizure or Convulsions Y N Weakness Y N Stroke Y N Alzheimer’s Y N Pseudotumor cerebri Y N Multiple Sclerosis Y N Frequent severe headaches Y N Knocked Unconscious Y N Surgery Y N Cancer Y N Breast:_____________________________________________________________________________________ Lumps Y N Pain Y N Fibrocystic disease Y N Nipple discharge Y N Surgery Y N Cancer Y N Skin:________________________________________________________________________________________ Rashes under skin folds Y N Keloids (excessively raised scars) Y N Poor wound healing Y N Frequent skin infections Y N Surgery Y N Cancer Y N Blood:_______________________________________________________________________________________ Anemia (iron deficient) Y N Anemia (vitamin B12 deficient) Y N HIV Y N Low platelets (thrombocytopenia) Y N Lymphoma Y N Swollen lymph nodes Y N Superficial blood clot in leg Y N Deep blood clot in leg Y N Blood clot in lungs Y N Bleeding disorder Y N Blood transfusion Y N Blood and thinning medicine use Y N Psychiatric:__________________________________________________________________________________ Anxiety Y N Depression Y N Anorexia Y N Bulimia Y N Bipolar disorder Y N Alcoholism Y N Drug dependency Y N Schizophrenia Y N Other psychiatric problems Y N Hospitalization for psychiatric problems Y N Have you ever been in a psychiatric hospital? Y N Have you ever attempted suicide? Y N Have you ever been physically abused? Y N Have you ever seen a psychiatrist or counselor? Y N Are you currently seeing a psychiatrist or counselor? Y N Have you ever taken medications for psychiatric problems or for depression? Y N Have you ever been in a chemical dependency program? Y N Constitutional:________________________________________________________________________________ Fevers Y N Night Sweats Y N Anemia Y N Weight Loss Y N Chronic Fatigue Y N Hair Loss Y N Thank you for filling out the questionnaire honestly and completely.
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