BMI of Texas 9910 Huebner Rd, Suite #250 San Antonio TX 78240
advertisement
BMI of Texas 9910 Huebner Rd, Suite #250 San Antonio TX 78240 Phone (210)615-8500 Fax (210)615-8501 New Bariatric Surgery Patient Intake Questionnaire In order to minimize your wait time and maximize your experience at BMI of Texas, please take a moment to complete this questionnaire. We realize this is a lengthy form but assure you it is all important information and will be kept confidential. Please Print First Name: ________________________Last Name: _______________________DOB:_________________ Preferred Surgeon (circle one): Desired Procedure: Michael Seger, MD Terive Duperier, MD First Choice Richard Englehardt, MD Second Choice Roux-En-Y Gastric Bypass Roux-En-Y Gastric Bypass Adjustable Gastric Band Adjustable Gastric Band Gastric Sleeve Gastric Sleeve Revision Revision Undecided Undecided Chief Complaints: Morbid Obesity Fatty Liver (alcoholic) Osteoarthritis - Hip Asthma Fatty Liver (non-alcoholic) Osteoarthritis - Knee Decreased Quality of Life Gastroesophageal Reflux Disease Pulmonary Disease Deep Venous Thrombosis Heart Disease w/o CABG Sleep Apnea w/ CPAP Depression Heart Disease w/ CABG Sleep Apnea w/o CPAP Diabetes Type I Inability to Lose or Maintain Weight Urinary Stress Incontinence Diabetes Type II Joint Pain Venous Stasis Dyslipidemia Low Back Pain Edema Menstrual Abnormalities CONTINUE TO NEXT PAGE Staff Use Only: Advocate: ______________________________________ Surgeon: ____________________________ Appointment Date: ___________________________________ Time: __________________________ Adipose Relate Comorbities Diabetes Date of onset: ________________ Taking Rx? ________________ Hypertension Date of onset: ________________ Taking Rx? ________________ Sleep Apnea Date of onset: ________________ Taking Rx? ________________ CAD Date of onset: ________________ Taking Rx? ________________ PVD Date of onset: ________________ Taking Rx? ________________ Venous Disease Date of onset: ________________ Taking Rx? ________________ Hyperlipidemia Date of onset: ________________ Taking Rx? ________________ COPD Date of onset: ________________ Taking Rx? ________________ Renal Insufficiency Date of onset: ________________ Taking Rx? ________________ Arthritis Date of onset: ________________ Taking Rx? ________________ GERD Date of onset: ________________ Taking Rx? ________________ Weight History How many years have you been at your current weight? ______________ How many years have you been obese? ___________ How many years have you been more than 35 pounds overweight? __________ How many years have you been more than 100lbs overweight? _________ At what age did you start to diet? _______________ What is your maximum weight you’ve reached? ________________ What was your most significant amount of weight loss? _____________ How long was this loss sustained? ________________________________________________________ What was your method of weight loss? ____________________________________________________ Do you consider yourself to be: (circle all that apply) Volume Eater -- Sweet Eater -- Snacker/Grazer -- Emotional Eater -- Binge Eater Please indicate which unsupervised diets you have tried in the past: Atkins Health Spa Pritkin AYDS Herbal Life Richard Simmons Binging/Purging High Protein Stillman Diet Body for Life/Bill Phillips Home Gym Equipment Slim Fast Calorie Counting Hypnosis South Beach Diet Gloria Marshall Low Carbohydrates Sugar Busters Gym Membership Mayo Clinic Diet Zone Scarsdale Diet Other ___________ Please indicate which supervised diets you have tried in the past: Acupuncture Medifast Physician Wt. Loss Center Diet Center Metrical Psychological Counseling Diet Pills from MD National Weight Loss Supervised Calorie Counting Diet Shots from MD Nutri-System T.O.P.S Exercise Counseling Nutritional Counseling Weigh of Life Health Management Resources Optifast Weight Watchers New Direction Overeaters Anonymous Other ___________________ Jenny Craig Personal Trainer Please indicate which weight loss medications you have tried in the past: Accutrim Fenfluramine Phentermine/Fastin/Adipex Amphetamines Herbal Remedies Phentrol Anorex Ionamin Plegine Benzphetamine Laxatives Pondimin Dexatrim Mazanor Redux Didrex Meridia Sanorex Diuretics Metabolife Tepanol Fastin Obalan Tenuate Fen-Phen, Orlistat/Xenical/Alli Topomax Phendiet Wehless # of months used ______ Other ___________ Please indicate which methods of exercise you have previously tried to lose weight. Sedentary Weight Training Walking or Running Group Classes Stationary Cycle Jogging Treadmill Tennis/Racquet Sports Swimming Team Sports Other: __________________ Please indicate if you have utilized any of the following to assist with your weight loss attempts: Hospitalization Psychological Therapy Hypnosis Residential Programs Physical Therapy Support Groups Other: __________________ Medical History Please carefully review the list of medical conditions/problems listed below and check any that apply to you: GERD Osteoarthritis – Shoulder Angina Helicobacter Pylori Osteoarthritis – Wrist Arrhythmia Hemmorrhoids Osteopenia Cardiac Palpitations Hiatel Hernia Osteoporosis Cardiomyopathy Rectal Bleeding Pain – Ankles/feet Congestive Heart Failure Ulcer – Duodenal Pain – Back DVT (blood clot) Ulcer – Esophageal Pain – Elbows Dyspnea with Exertion Ulcer – Gastric Pain – Hands Cardiac Autoimmune Heart Disease w/o CABG Pain – Hips Heart Disease w/ CABG Crohn’s Disease Pain – Knees Heart Murmur Lupus Pain – Neck Hypercholesterolemia Metabolic Syndrome Pain – Shoulder Mitral Valve Regurgitation Psoriatic Arthritis Pain – Wrist Myocardial Infarction Rheumatoid Arthritis Scoliosis Peripheral Edema Sarcoidosis Peripheral Vascular Disease Ulcerative Colitis Varicose Veins Venous Insufficiency Cancer Gynecological Psychosocial Alcoholic Anxiety Amenorrhea Bipolar Disorder Dysfunctional Uterine Depression Neurological Breast Cancer Bleeding Lymphedema Dysmenorrhea CVA Skin Cancer Gestational Diabetes Insomnia Cancer Infertility Intracranial Hypertension Menstrual Irregularity Migraine Headaches Polycystic Ovary Disease M ultiple Sclerosis Infectious Disease Hepatitis B Musculoskeletal Hepatitis C Narcolepsy HIV/AIDS Carpel Tunnel Syndrome Neuralgia Paresthetica MRSA History Chronic Back Pain Pseudotumor Cerebri Lyme Disease Degenerative Disk Disease Seizure Disorder Tuberculosis Exposure DJD Sleeping Disorder Gastrointestinal Urinary Fibromyalgia Barrett’s Esophagus Joint Pain BPH Cholelithaisis/Cholecystitis Osteoarthritis – Ankles/Feet Nocturia Colitis Osteoarthritis – Elbows Frequent UTI Elevated Liver Enzymes Osteoarthritis – Hands Prosatitis Fatty Liver (alcoholic) Osteoarthritis – Hips Renal Lithiasis Fatty Liver (non-alcoholic) Osteoarthritis – Knees Stress Urinary Incontinence Gastroparesis Osteoarthritis – Neck/back Urinary Incontinence Abdominal Gout Hernia Hypothyroidism Hernia – Incisional Morbid Obesity Hernia – Inguinal Pancreatitis Hernia – Umbilical Pituitary Tumor Hematological Abnormal Bleeding Anemia Blood Clotting Disorder Thyroid Disease Eyes Coagulopathy Pulmonary Glaucoma Skin Cellulitis Interiginous Dermatitis Psorasis Endocrine Diabetes Type I Factor V Leiden Asthma Hypercoaguable State Bronchitis Thrombocytopenia Pneumonia Thrombophlebitis COPD Transfusion History Pulmonary Embolus Antibiotics before dental work Seasonal Allergies Other: ___________________ Sleep Apnea, no CPAP Diabetes Type II Gluclose Intolerance Sleep Apnea CPAP No medical History Dependent Surgical History: Please list non-bariatric surgeries (surgeries not related to weight loss) you have had or indicate if you have not had any. No prior non-bariatric surgeries Example: Open Hysterectomy w/ ovaries removed, 1/25/99, no complications Procedure/Surgery: specify laparoscopic/Open Date: Please list previous bariatric (weight loss) surgeries: Complications: No prior bariatric surgeries Procedure/Surgery: (laparoscopic/Open) Date: Original Weight: Lowest Weight Complications: Medications: Please list below any and all medications/vitamins you are currently taking. Example: Lipitor 10mg one tablet daily at bedtime 1.____________________________________________________________________________________ 2.____________________________________________________________________________________ 3.____________________________________________________________________________________ 4.____________________________________________________________________________________ 5.____________________________________________________________________________________ 6.____________________________________________________________________________________ 7.____________________________________________________________________________________ 8.____________________________________________________________________________________ 9.____________________________________________________________________________________ 10. ____________________________________________________________________________________ Not currently taking any medications Allergies: Do you have allergies to any of the following: Medications, if so, please list medication and reaction: __________________ _______________________________________________________________ _______________________________________________________________ Latex Iodine, when: ____________________________________________________ IV Contrast, when: ________________________________________________ Adhesives, type: _________________________________________________ No Known Allergies Disability: Are you currently considered to be disabled by the U.S. Social Security Administration? No Yes If yes, for what reason are you disabled? Year of disability: ________________ Motor vehicle accident Disability due to recent disabling illness Work related disability Disability due to chronic medical condition: (describe)__________________________ Do you require assistive device? Yes If yes, indicate which type? Cane Crutches No Walker Braces Do you utilize a wheelchair or motorized scooter? Yes No If yes, how long have you required this assistance? __________________________________ Family History: (Please include only parents, grandparents, and siblings) Illness/Medical Condition Family Member _________________________________ __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ Social History: Do you currently smoke? No Rarely Occasionally Frequently If yes, How many packs per day? _______________ For past smokers How many years ago did you quit smoking? ____________ How many years did you smoke? ______________ How many packs a day did you smoke? _________________ Do you drink alcohol? No Rarely Occasionally Frequently If yes, how many times/week? __________________________ Do you currently use illicit/street drugs? No Rarely Occasionally Frequently If yes, what type did/do you use and how often? _________________________________________ *Note to patient: We apologize for the length of this form but we feel that all of this information is very important to enable our office and staff to provide you with excellent care. Review of Systems Neurologic Ataxia Dizziness Headaches Insomnia Paralysis Parethesia Sensory Loss Seizures Sleepiness Stroke Syncope Weakness Psychosocial Alcohol Use Confirmed Mental Health Disorder Depression Enrolled in Chemical Dependency Inpatient Psychiatric Care Mental/Emotional Abuse Physical Abuse Psychosocial Impairment Seen Psychiatrist or Counselor Sexual Abuse Substance Abuse Suicide Attempt Tobacco Use Head and Neck Epistaxis Hearing Problems Hoarseness Lymphadenopathy Constitutional Appetite Change Chills Fatigue Fevers Hair Loss Night Sweats Weight Change Cardiovasuclar Angina Congestive Heart Failure Deep Venous Thrombosis Hypertension Irregular/Skipped Heart Beat Ischemic Heart Disease Lower Extremity Edema Pacemaker Peripheral Vascular Disease Rapid Heart Rate Rheumatic Fever / Value Damage/ MVP Varicose Veins Respiratory Obstructive Sleep Apnea Pulmonary Hypertension Asthma Obesity Hypoventilation Syndrome Chronic Cough Shortness of Breath at Rest Emphysema/COPD Bronchitis Pneumonia Endocrine/Metabolic Abnormal Facial Hair Growth Diabetes Type I Diabetes Type II Dyslipidemia Elevated Calcium Level Endocrine Gland Tumor Excessive Thirst Excessive Urination Goiter Gout Hyperthyroid (overactive) Hypothyroid (low thyroid) Low Blood Sugar Parathyroid Problems Hematological Anemia Anemia (Fe deficiency) Anemia – Pernicious (B12 deficiency) Anticoagulant Use Coagulopathy Easy Bleeding Gastrointestinal Abdominal Pain Barrett’s Esophagus Black Tarry Stools Blood in Stool Change in Bowel Habits Colitis Colon Polyps Constipation Crohn’s Disease Diarrhea Difficulty Swallowing Gallstones GERD Heartburn Hemorrhoids Hiatel Hernia Incisional Hernia Irritable Bowel Liver Disease Nausea / Vomitting Pancreatic Musculoskeletal Autoimmune Disease Back Pain Broken Bones Carpel Tunnel Syndrome Fibromyalgia Lupus Musculoskeletal Disease Plantar Fasciitis Rheumatoid Arthritis Sciatica Scleroderma Ankle Pain Ball of foot/toe pain Foot Pain Hip Pain Knee Pain Muscle Pain Neck Pain Shoulder Pain Wrist Pain Gynecological Polycystic Ovarian Syndrome Menstrual Irregularities Breast Cancer Breast Masses Fibrocystic Disease Infertility Mastodynia (Breast Pain) Nipple Discharge Post Menopausal Uterine/Ovarian Cancer Last Pap ____________________________ Last MMG __________________________ Are you pregnant? ____________________ Are you planning more children? ________ How many pregnancies? _______________ How many children? __________________ How many miscarriages/abortions? ______ Urinary Dysuria Hematuria Hesitancy Kidney Failure/Renal Insuff Kidney Stones Leaking Urine when Sneezing Nocturia Previous PSA Test (male) Prostate Problems Trouble Starting Urination Urinary Frequency Urinary Incontinence Urinary Urgency Dermatological Hair/Nail Changes History of MRSA Intertrigo Lesions Masses Non-Healing Wounds Rashes
