Patient Name by mikesanye


									                                   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

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:
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
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
   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
                                                                 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
                                                                    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
                                                                    or done

         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
                                                            o Severe, requiring hospitalization

                                                   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
                                                                           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
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
   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
***Please note that if you are not familiar with a listed condition, then it may not pertain to you!

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
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
Use of CPAP or oxygen supplement Y            N                       Tuberculosis                         Y    N
Pulmonary Embolism                            Y       N                       Hypoventilation Syndrome          Y
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
Hypothyroid (low)                      Y      N                       Hyperthyroid (high/ overactive)      Y    N
Goiter                                 Y      N                       Parathyroid                          Y    N
Elevated Cholesterol                   Y      N                       Elevated Triglycerides                    Y
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

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
Crohn’s                               Y       N                       Hemorrhoids                      Y    N
Fissure                                       Y       N                        Rectal Bleeding              Y
Black, tarry stool                    Y       N                       Polyps                           Y    N
Abdominal pain                        Y       N                       Enlarged Liver                        Y
Cirrhosis/ hepatitis                  Y       N                       Gallbladder problems                  Y
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
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
Excessively heavy periods             Y      N                      Do you plan to have more children?           Y
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?
               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
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
Dentures/ Partial                     Y      N                      Oral Sores                             Y     N
Hoarseness                            Y      N                      Head/ Neck Surgery                     Y     N
Cancer                                Y      N
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
Frequent severe headaches              Y       N                       Knocked Unconscious                         Y
Surgery                                Y       N                       Cancer                                 Y    N
Lumps                                  Y       N                        Pain                                  Y    N
Fibrocystic disease                    Y       N                        Nipple discharge                      Y    N
Surgery                                Y       N                       Cancer                                 Y    N
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
Blood clot in lungs                    Y       N                       Bleeding disorder                      Y    N
Blood transfusion                      Y       N                       Blood and thinning medicine use        Y    N
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
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
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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