Health History Form

The information provided in this form is vitally important in the planning of your surgical care. Omission of complete and accurate information to the physician could result in the delay or cancellation of your surgery as well as jeopardize the ability of the physician to provide the best possible care.

  = required field
Patient Information
First Name:       M. I.: 
Last Name:    
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Birth Date:     Age:     Race: 

Marital Status:

 Single:    Married:    Widowed:    Divorced:
.

Address:

City:

     State:     Zip: 
.

Home Phone:

 - -  

Cell Phone:

 - -

Social Security:

     E-mail:  
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Employer:

     Occupation: 

Phone:

 - -

Address:

City:

     State:     Zip: 
.

Emergency Contact:

     Relationship: 

Phone:

 - -

Address:

City:

     State:     Zip: 
.

Insured Name:

     Insurance Renewal Date: 

Address:

City:

     State:     Zip: 

Birth Date:

     Social Security No.: 
.

Employer:

     Occupation: 

Address:

City:

     State:     Zip: 
.

Primary Care Physician:

Phone:

 - -

Address:

City:

     State:     Zip: 
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May we send your PCP information about your case?    Yes    No

Are you receiving disability benefits?    Yes    No

Reason for Disability:
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I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY INSURANCE CLAIMS. I AUTHORIZE PAYMENT OF INSURANCE BENEFITS TO FOR HIS SERVICES.
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Electronic Signature:

     Date: 

Parent Signature (if under 18):

     Date: 
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How did you hear about Weight Loss Surgery Specialists? 

What is your current Weight?      What is your current Height? 
Are you interested in:    Gastric Bypass     Lap-Band     Gastric Sleeve     Revision 
.
List any medical problems you have for which you have seen a doctor or been hospitalized.
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Illness
 
 
 
 
 
 		 Date
 
 
 
 
 
 		 Treatment
 
 
 
 
 
 		 Outcome
 
 
 
 
 
 
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Have you been diagnosed or treated for high blood pressure? Yes    No
Have you been diagnosed or treated for diabetes?   Yes    No
Do you have high blood cholesterol?   Yes    No
Do you have high blood fats or triglycerides?   Yes    No
Have you ever been diagnosed with asthma?   Yes    No
Have you been diagnosed or treated for heartburn or gastro-esophageal reflux (GERD)?   Yes    No
Have you ever had stomach ulcers?   Yes    No
Have you ever had blood clots in your leg veins?   Yes    No
Have you ever been anemic?   Yes    No
Have you ever had iron deficiency or taken iron?   Yes    No
Have you ever been diagnosed with hypothyroidism?   Yes    No
Have you ever had thyroid surgery?   Yes    No
Do you take thyroid replacement medication?   Yes    No
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List all surgeries and specify if done open or laparoscopically.
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Surgery Date Reason Open or Lap
         
         
         
         
         
         
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Have you had Weight loss surgery before?   Yes No   If Yes when and what type of surgery:

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Does your religion prohibit you from receiving blood products? Yes    No
Have you had your gallbladder removed?   Yes    No
Have you had a hysterectomy?   Yes    No
Have you had a tubal ligation or had your "tubes tied"?   Yes    No
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List all current medications, including prescriptions, vitamins, over-the-counter, and intermittently used drugs.
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Name Strength How Often Taken Purpose When First Started <-- Required Daily
--> As Needed
              
              
              
              
              
              
              
              
              
              
              
              
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List any allergies to medication and explain reactions you experienced.

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Do you take aspirin on a daily basis? Yes    No
Do you take Plavix?   Yes    No
Do you take Coumadin?   Yes    No
Do you take Prednisone or Dexamethasone?   Yes    No
Have you ever smoked tobacco products?   Yes    No
If yes, how many years? 
How many cigarettes per day? 
.    
Do you currently use tobacco products?   Yes    No
If yes, how many per day?
.    
Do you get chest pain when exercising?   Yes    No
Do you get short of breath at rest?   Yes    No
Do you get short of breath when exercising?   Yes    No
Do you experience irregular or excessively strong heartbeats?   Yes    No
Do you sleep lying flat?   Yes    No
Do you wake up at night short of breath?   Yes    No
Have you had any blackouts?   Yes    No
Do you get swollen ankles?   Yes    No
Have you had easy or excessive bleeding from surgery or minor injuries?   Yes    No
Have you had easy bruising?   Yes    No
Do you have heavy periods?   Yes    No
Are you still having periods?   Yes    No
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Sleep Apnea Self Test
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The quiz is designed to alert you to any problems resulting from poor sleep. Please answer the questions below. If you have had any symptoms in the past year, mark the box below and add up the total.
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(20)

1. I have been told that I snore or I know that I snore.

(-50)

2. I definitely do not snore.

(0)

3. I do not know if I snore.

(10)

4. I have been told that I stop breathing when I sleep.

(10)

5. I wake up choking.

(5)

6. I sweat excessively at night.

(-5)

7. (If female and above is true) I have hot flashes related to my cycle.

(2)

8. I am tired and sleepy during the day even after 8 hours of sleep.

(2)

9. I wake up tired and unrested.

(10)

10. I suddenly wake up unable to breathe.

(5)

11. I have fallen asleep while driving.

(5)

12. I am a restless sleeper (toss and turn a lot).

(20)

13. My neck circumference is more than 17 inches. (ask office staff to measure if unknown)

(5)

14. I frequently have morning headaches.
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Total (more than 30 points suggests that you have SLEEP APNEA.)
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Do you sleep with a C-Pap? Yes    No
Do you sleep with a Bi-Pap?   Yes    No
Have you ever received psychiatric treatment?   Yes    No
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Diagnosis or reason for treatment:
Last treatment date:
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Treated by:

 Psychiatrists   Psychologists   Physician

Physicians Name:

Address:

Phone:

- -
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Dietary History
Please complete this form as precisely as possible.
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Diet Programs   # Times Tried   Dates Tried   Length of Time
on Diet		   # Lbs. Lost   # Lbs. Regained
Example:   3   1990/93/95   2-3 months each   5-24 lbs   All+
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M.D. SUPERVISED
Medi-Fast:          
Opti-Fast:          
Mayo Clinic:          
Physician Diet Program:          
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SHOTS
    # Times Tried   Dates Tried   Length of Time
on Diet		   # Lbs. Lost   # Lbs. Regained
B-6:          
B-12:          
Other:          
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PILLS
    # Times Tried   Dates Tried   Length of Time
on Diet		   # Lbs. Lost   # Lbs. Regained
Lasix (diuretic):          
Xenical:          
Meridia:          
Other:          
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M.D./Clinic Name:
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NON M.D. SUPERVISED
    # Times Tried   Dates Tried   Length of Time
on Diet		   # Lbs. Lost   # Lbs. Regained
Weight Watchers:          
Nutri-Systems:          
Jenny Craig:          
Diet Center:          
TOPS:          
Overeaters Anonymous:          
Other:          
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LIQUID DIETS
    # Times Tried   Dates Tried   Length of Time
on Diet		   # Lbs. Lost   # Lbs. Regained
Slimfast:          
Sweet Success:          
Liquid Protein:          
Other:          
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MISCELLANEOUS DIETS
    # Times Tried   Dates Tried   Length of Time
on Diet		   # Lbs. Lost   # Lbs. Regained
Low Calorie Diet:          
Low Fat Diet:          
High Protein Diet:          
Self-Imposed Fasts:          
Richard Simmons:          
Herbal Life:          
Cambridge Diet:          
Dr. Atkins Diet:          
Other:          
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DIET PILLS (over the counter)
    # Times Tried   Dates Tried   Length of Time
on Diet		   # Lbs. Lost   # Lbs. Regained
Acutrim:          
Dexatrim:          
Metabolife:          
Xenadrine:          
Other:          
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OTHER TYPES OF WEIGHT LOSS
    # Times Tried   Dates Tried   Length of Time
on Diet		   # Lbs. Lost   # Lbs. Regained
Psychotherapy:          
Acupuncture:          
Hypnosis:          
Subliminal Tapes:          
Other:          
.
EXERCISE                    
  # Times Tried Dates Tried Length of Time
on Diet		 # Lbs. Lost # Lbs. Regained
Health Club:          
VCR Tapes:          
Other:          
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How long have you been overweight?      Age began first diet?  
Most weight you ever lost?      How was weight loss obtained? 
Are you a snacker?  Yes  No    Favorite foods: 
Do you eat a lot of sweets?  Yes  No    How often do you eat sweets? 
Are you currently under a physicians care for weight loss?  Yes  No
If yes, name and address: 
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I have provided complete and accurate information to the best of my knowledge.
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