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Do not write above this line
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DEMOGRAPHICS
Name: ___________________________________
Date of Birth: _____________ Date: ______________
Email Address (print clearly): ______________________________Height: _________ Weight: __________
Full Address:_______________________________________________________________________________
Cell: ___________________ Home Phone: ________________ Work Phone: ________________
May we email you?
Yes
No
Best number to call: ______________________________
Insurance Plan: ___________________Policy Number: ______________________Group:________________
Insurance phone number: _____________________ Secondary Insurance: _____________________________
Does your policy have the obesity surgery rider? (please call them to find out) ____________
How did you hear about us?_________________________________________________________________
Education (circle or describe): ______________________________________________________________
Some high school
Marital status:
single
HS graduate
married
GED
Some college
separated
College Graduate
divorced
widowed
Masters
Doctorate
engaged
With whom do you live?_____________________________________________
Employment status: Working
Disabled
Student
Other: _______________________
Occupation:________________________________ Employer: ________________________________
Have you ever seen anyone in our group before?_________ If yes, who? ______________________________
Surgeon preference (circle): Dr. Rocha Campos
Dr. Bittner
Dr. Aquilina
Surgery preference (circle): Lap Gastric Bypass Lap Gastric Sleeve Revision
First available
Lap Gastric Band Not Sure
The following sections will help your surgical team learn more about you and your medical/surgical
history. Please answer all questions (front and back) completely.
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Medical History
Include past and current medical problems
Medical Condition
Short winded, have shortness of breath or
trouble breathing
If yes, what causes it?
Asthma or COPD
High blood pressure or hypertension
High Cholesterol or Triglyceride levels
Chest pain
If yes, what causes it?
Seen a heart doctor or had a work up for
possible heart problems
Heart attack
Heart disease, blocked arteries, congestive
heart failure, or any other heart problems
Swelling in your legs
Dark or discolored skin on your lower legs
Ulcer or sore on your leg that took a long time
to heal
Ulcerative Colitis, Crohn’s disease, Irritable
Bowel or another GI disease
Stomach ulcer
Heartburn
Reflux (GERD)
Hiatal hernia
Liver disease
Leak urine when you cough, sneeze or laugh
Women: Irregular or abnormal menstrual
cycles (periods)
Women: PCOS
Women: Difficulty getting pregnant
Kidney stones
Kidney disease
Kidney failure
Blood clot in your legs
Blood clot in your lung/pulmonary embolism
Blood clot in the legs or lungs of a family
member
History of blood disorder, bleeding disorder
or clotting disorder (such as Factor V Leiden)
in you or family member
Yes
No
Comments
If yes, circle: Asthma or COPD
If yes, please circle:
high cholesterol
high triglycerides
If yes, Please obtain notes and any tests done
and bring them to your appointment.
If yes, please explain:
If yes, list:
If yes, when?
If yes, explain:
If yes, do you wear a pad?
If yes, explain:
If yes, explain:
If yes, explain:
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Medical Condition
Sickle Cell or Sickle Cell Trait
Diabetes
Insulin for Diabetes
Diabetes in pregnancy
Thyroid problems
HIV, AIDS, Hepatitis B or Hepatitis C,
MRSA (circle all that apply)
Fibromyalgia
Chronic Fatigue Syndrome
Cancer
Joint pain (circle)
Need joint replacement (circle)
Need assistance with walking (circle)
Back pain
MS, MD or any other neuromuscular disease
Migraines
Pseudotumor Cerebri
Past or current treatment by a mental health
professional such as a psychiatrist,
psychologist, counselor or social worker
Past or current medication for depression,
anxiety, bipolar disorder, bad nerves, or any
other mental health problem
Depression
Anxiety
Bipolar disorder
Bad nerves
Schizophrenia
Borderline personality
PTSD
OCD
ADD/ADHD
Other (List)
Psychiatric hospitalizations
Alcohol abuse or dependence
Drug dependence (past or current)
Eating disorder (If yes, circle appropriate)
Yes
Recent thoughts about harming yourself or
someone else
Have you ever tried to take your own life?
Other medical problems not listed above:
No
Comments
If yes, who is your treating doctor?
Back
Hip
Cane
Hips
Knees
Ankles
Knee
Wheelchair
Walker
List:
If yes, explain:
If yes, explain:
Binge eating
Other:
Anorexia
Bulimia
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Sleep Habits
Have you had a sleep study? � Yes � No
Have you been diagnosed with Obstructive Sleep Apnea? � Yes � No
If yes, do you use CPAP? � Yes � No
Do you snore? � Yes � No
Do you awake frequently from sleep? � Yes � No
Have you been told that you stop breathing in your sleep? � Yes � No
Are you frequently sleepy in the daytime? � Yes � No
Each item below describes a routine daytime situation. Use the scale below to rate the likelihood that you would
doze off or fall asleep (in contrast to just feeling tired) during that activity during the day. If you haven’t done
some of these things recently, consider how you think they would affect you.
Use the following scale to choose the most appropriate number for each situation:
0 = Would never doze off
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Sitting and reading
Watching TV
Sitting inactive in a public place, for example a theater or meeting
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
Surgery (List all surgery you have had) or if no surgery, circle: NONE
Type of Surgery
lap or open?
Date(s)
Reason for Surgery
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Social
Yes
Current smoker
Past smoker
Smokeless tobacco, gum or patches
Current or past use of marijuana
Experiment with harder drugs
Problems with prescription drugs such as pain
pills, nerve pills, diet pills or sleeping pills
Have you done any research about surgery?
Do your family and/or significant others know
you are considering surgery?
If yes, do they support surgery?
Who will your caregiver(s) be if you have
surgery?
No
Comments
If yes, how much?
Last cigarette:
If yes, explain:
List:
Current Substance Use Habits
Do you drink alcohol? � Yes � No
If yes, how often? � Daily � Weekly � Occasionally � Rarely � Never
In an average week, how many alcoholic drinks (beer, wine and/or liquor) do you have? ______________
What do you typically drink: _____________________What is the highest number of drinks you have? _____
Do you drink caffeinated beverages (coffee, soda, tea, etc.) � Yes � No
If yes, how often? � Daily � Weekly � Occasionally � Rarely � Never
In an average day, how many caffeinated drinks (coffee, tea and/or soda) do you have? ______________
Family History
List your mother, father, brothers and sisters and any known health problems.
If deceased, note age at death and cause of death.
Allergies
Please list any allergies you may have (including latex) and how you react to the allergen (example,
allergic to sulfa drugs, break out in hives).
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Medications/Pharmacy:
List all prescription medications, over the counter medications and vitamins you currently take. Attach a
list if additional space is needed:
Name of medication
Dose
How often
Reason for taking
Name of your pharmacy: ______________________________________________
Pharmacy’s Street and City: _______________________________________
If you do not currently have a pharmacy, please select one in your area and provide information above.
Diet History
What is the longest you ever really stuck with any weight loss program?____________________
Which program did you stick with the longest?________________________________________
What is the most weight you have ever lost? ___________________ lbs.
On which program did you lose the most weight?_____________________________________
Have you ever starved yourself down to a dangerously low weight? _____Yes _____No
Have you ever made yourself vomit to keep from gaining weight? _____Yes _____No
Have you ever used laxatives to lose weight? _____Yes _____No
Did you ever take the combination of weight loss pills known as Phen-fen? _____Yes _____No
Did you ever count calories to lose weight? _____Yes _____No
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Did you ever count fat grams to lose weight? _____Yes _____No
Do you participate in a regular exercise program beyond your usual daily activities? ____Yes ____No
If you exercise, how many days a week do you usually exercise? ______ How long? _______ minutes
If you exercise, what activity do you engage in for exercise? ____________________________
Have you participated in ‘formal’ diet plans?
Yes
No
Have you tried dieting on your own?
Yes
No
Diet Program
Dietitian
Physician-supervised
Weight Watchers
Nutri System
Phen-Fen
Overeaters Anonymous
Jenny Craig
American Weight Loss
Atkins
South Beach
Herbal Life or Metabolife
Other (please list):
When
(If yes, please list in the chart below)
For How Long? Pounds lost
Other diets not listed above:
Age when you first developed a weight problem____________
Weight 1 year ago: ___________
Weight 5 years ago: ___________
Pounds regained
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Diet Recall
Please complete the following food diary as honestly and as detailed as possible. Include one
weekday and one weekend day, food, amount consumed, time of day, and how the food was
prepared. Include snacks and beverages (with amounts consumed):
Day 1 (weekday)
Day 2 (weekend)
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Physician Information
Please list names, phone & fax numbers, and addresses of all of your doctors (including
primary care physician, heart doctor, psychiatrist, therapist, or any others).
If you do not know the address (including zip code) and fax numbers, call your doctor’s
office and obtain complete mailing address and fax number.
Physician’s name
Specialty
Phone
Number
Fax
Number
Address (street number, city,
state, zip code)
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