BMI of Texas
9910 Huebner Rd, Suite 250
San Antonio TX 78240
(210)615-8500 Phone
(210)615-8501 Fax
New General 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):
Michael Seger, MD
Terive Duperier, MD
Richard Englehardt, MD
What are you here for today?
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Who referred you to our practice? _____________________________________________________
Please list all Doctor’s you follow up with:
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CONTINUE TO NEXT PAGE
For office use only:
Appointment date: ___________________________ Time: ________________
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: __________________
_______________________________________________________________
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
Latex

Iodine, when: ____________________________________________________

IV Contrast, when: ________________________________________________

Adhesives, type: _________________________________________________

No Known Allergies
Medical History
Please carefully review the list of medical conditions/problems listed below and check any that apply
to you:
 Angina

Glucose Intolerance
 Allergic Rhinitis

Gout
 Anxiety

Heartburn/Indigestion
 Asthma

Hemorrhoids
 Breast Cancer

High Cholesterol
 Heart Disease w/bypass surgery

Hypertension (high blood pressure)
 Heart Disease without bypass surgery

High triglycerides
 Cardiomyopathy

Hypothyroidism (Underactive thyroid)
 Carpal Tunnel Syndrome

Infertility
 Chest pain with exertion/exercise

Insomnia
 Gallstones
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Intermittent Claudication
 Chronic Back Pain

Intertriginous Dermatitis (irritation of the skin folds)
 Congestive Heart Failure

Irritable Bowel Syndrome
 Stroke

Joint Pain
 DVT (Blood Clot)

Menstrual Irregularity
 Degenerative Disk Disease

Migraine Headaches
 Depression

Myocardial Infarction (Heart Attack)
 Type I Diabetes/Insulin Dep (controlled)

Swelling of the legs (edema)
 Type I Diabetes/Insulin Dep (Uncontrolled)

Peripheral Vascular Disease
 Type II Diabetes/Adult Onset (Controlled)

Stomach Ulcers
 Type II Diabetes/Adult Onset (Uncontrolled)

Polycystic Ovarian Syndrome (PCOS)
 Abnormal Uterine Bleeding

Pseudotumor Cerebrii
 Dysmenorrhea (Excessively painful menses)

Pulmonary Embolus (blood clot to lungs)
 Shortness of breath with exertion/exercise

Seasonal Allergies
 Abnormally elevated liver function tests

Sleep Apnea
 Fatigue

Sleeping Disorder
 Fatty liver (due to alcohol)

Stress Urinary Incontinence (leaking urine with
 Fatty liver (NOT related to alcohol)
cough/straining)
 Fibrocystic breast disease

Thrombophlebitis
 Fibromyalgia

Urinary Urge Incontinence (can’t hold urine)
 Acid Reflux Disease/GERD

Varicose Veins
 Gestational Diabetes (diab w/pregnancy)

Venous Insufficiency
*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.
Surgical History:
Please list non-bariatric surgeries (surgeries not related to weight loss) you have had or indicate if
 No prior non-bariatric surgeries
you have not had any.
Example: Open Hysterectomy w/ ovaries removed, 1/25/99, no complications
Procedure/Surgery:
Date:
**specify laparoscopic or Open
Complications:
Please list previous bariatric (weight loss) surgeries:
 No prior bariatric surgeries
Procedure/Surgery:
(laparoscopic/Open)
Date:
Original Weight:
Lowest Weight
Complications:
Family History: (Please include only parents, grandparents, and siblings)
Illness/Medical Condition
Family Member
_________________________________
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_________________________________
__________________________________
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Social History:
Do you currently smoke?
 Yes
 No
If yes, how many years have you been smoking? ___________
Packs per day? _______________
For past smokers, what year did you quit? ____________How many years did you smoke? _______
Do you drink alcohol?
 Yes
 No
If yes, how many times/week or month? __________________________
Do you use illicit/street drugs?
 Yes
 No
If yes, what type did/do you use and how often? _________________________________________
Review of Systems
General: Please check any/all that apply to you:
Functional Status: Check any/all that apply to you:
 No impairment
 Able to walk 200 ft with assist device (cane/crutch)
 Cannot walk 200 ft with assist device (cane/crutch)
 Requires wheelchair
 Bedridden
Pseudotumor Cerebri: Check any/all that apply to you:
 No Symptoms
 Headaches with dizziness, nausea, and/or pain behind eyes
 Headaches with visual symptoms, and/or controlled with diuretics
 MPI confirmed diagnosis of PTC
 Well controlled with stronger medications
 Requires narcotics, surgical intervention done or recommended
Abdominal Hernia: Check any/all that apply to you:
 No hernia
 Asymptomatic hernia, no prior operation
 Successful repair
 Recurrent hernia or size >15cm
 Chronic evisceration through large hernia or multiple failed repairs
Stress Urinary Incontinence: Check any/all that apply to you:
 No Symptoms
 Minimal and intermittent
 Frequent but not severe
 Daily occurrence, requires sanitary pad
 Disabling
 Failed surgery
General (Continued):
Abdominal Skin / Pannus
 No Symptoms
 Intertriginous irritation
 Pannus is large enough to interfere with ambulation
 Recurrent cellulitis or ulceration
 Surgical treatment
\
Skin
Please check any/all that apply to you:
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
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Rash under folds /breasts
Keloids/large scars
Poor Wound Healing

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Blood:
Please check any/all that apply to you:
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Anemia (Iron deficiency)
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Anemia (B12 deficiency)
HIV / AIDS
Low Platelets
Swollen Lymph Nodes
Superficial clot in leg
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Endocrine / Metabolic
Gout: Check any/all that apply to you:
 No gout present
 Hyperuricemia present but no symptoms
 Hyperuricemia present, on medications
 Arthropathy present
 Destructive joints present
 Disabled, no walking
Diabetes: Check any/all that apply to you
 No Diabetes
 Elevated fasting glucose
 Oral meds only
 Insulin only
 Insulin and oral meds
 Complications present
Hair/Nail Changes
Rosacea
Bleeding Disorder
Lymphoma
Blood Transfusion
Use of Blood Thinners
Easy Bruisability
Endocrine/Metabolic Continued:
Dyslipidemia: (abnormal cholesterol/triglycerides)
Check any/all that apply to you:
 No Dyslipidemia
 No treatment required
 Lifestyle change
 Single medication
 Multiple medication
 Poorly controlled
Please check any/all that apply to you:
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Excessive urination
Excessive thirst
Low blood sugar
Endocrine gland tumor
Elevated Calcium level
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Abnormal facial hair growth
Hypothyroid (low thyroid)
Hyperthyroid (overactive)
Parathyroid Problems
Goiter
Other: _________________________________________________
_________________________________________________
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Respiratory
Sleep Apnea-please check any/all that apply to you:

No history of sleep apnea

Symptoms but sleep study/test negative

Positive sleep study/test

Require appliance/CPAP at night

Have hypoxia (low oxygen) or dependent on oxygen

Have complications related to sleep apnea
Pulmonary Hypertension, check any/all that apply to you:

No history of Pulmonary Hypertension

Symptoms only (tiredness, shortness of breath, dizziness)

Confirmed diagnosis

Well controlled on medications

Require oxygen or stronger meds

Pt needs/requires or has had lung transplant
Respiratory (continued):
Asthma, check any/all that apply to you:

No history of Asthma

Occasional Mild Symptoms, not on any meds

Symptoms controlled on oral meds or inhalers

Well controlled with daily medications

Poorly controlled, requiring steroids or anticholinergics

Hospitalization in the last 2 years/history of intubation
Obesity Hypoventilation Syndrome: Check any/all that apply to you:

No history of OHS

Low oxygen on room air

Severely low oxygen

Pulmonary Hypertension

Right Heart Failure

Right heart failure/Left Ventricular Dysfunction
Please check any/all that apply to you:

Chronic cough





Shortness of Breath at rest
Emphysema/COPD
Bronchitis
Pneumonia
Suspicious of Sleep Apnea but not ever diagnosed
Psychosocial
Psychosocial Impairment: Check any/all that apply to you:
 No impairment
 Mild impairment, able to perform primary tasks
 Moderate impairment, able to perform most primary tasks
 Moderate impairment, unable to perform most primary tasks
 Severe impairment, unable to function
Confirmed Mental Health Disorder: Check any/all that apply to you:
 None
 Bipolar
 Anxiety/Panic Disorder
 Personality Disorder
 Psychosis
Psychosocial (continued):
Depression: Check any/all that apply to you:
 No Symptoms
 Episodic, no treatment required
 Moderate with some impairment, may require treatment
 Moderate with significant impairment, treatment indicated
 Severe, intensive treatment indicated
 Severe, hospitalization required
Check any/all that apply to you:
Alcohol Use:
Tobacco Use:
Substance Abuse:
 No alcohol
 No tobacco
 No
 Rarely
 Rarely
 Rarely
 Occasionally
 Occasionally
 Occasionally
 Frequently
 Frequently
 Frequently
Neurologic
Please check any/all that apply to you:





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Migraine
Balance disturbance
Seizure or Convulsions
Weakness
Recurrent headaches
Numbness and Tingling


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
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Dizziness
Stroke
Multiple sclerosis
Restless Leg
Knocked unconscious
Musculoskeletal Disease
Back Pain: Check any/all that apply to you:
 No Back Pain
 Intermittent symptoms
 Non narcotic treatment
 Degenerative changes, narcotic treatment
 Surgical treatment done or recommended
 Failed surgical treatment
Musculoskeletal Disease (continued):
Fibromyalgia: Check any/all that apply to you:
 No fibromyalgia
 Treatment with exercise
 Treatment with non narcotic medications
 Treatment with narcotics
 Surgical Treatment done or recommended
 Disabled, surgery failed
Musculoskeletal Disease: Check any/all that apply to you:
 No musculoskeletal disease
 Pain with community ambulation
 Non narcotic analgesia
 Pain with household ambulation
 Surgical intervention required
 Joint replacement done or recommended
Please check any/all that apply to you:




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Neck Pain
Shoulder Pain
Wrist Pain
Hip Pain
Knee Pain
Ankle Pain
Foot Pain
Heel Pain
Ball of foot / Toe Pain
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Lupus
Scleroderma
Autoimmune Disease
Muscle Pain
Sciatica
Plantar fasciitis
Carpal Tunnel
Rheumatoid arthritis
Broken Bones
Other: ________________________________________________
________________________________________________
Bladder: Check any/all that apply to you:





Kidney Stones
Blood in Urine
Prostate Problems
Burning on urination
Urinary Urgency



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Kidney Failure / Renal Insuff
Leaking Urine when Sneezing
Previous PSA test (males only)
Trouble Starting
Gastrointestinal
Please check any/all that apply to you:





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
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Abdominal Pain
Heartburn
Stomach Ulcers
Hiatel Hernia
Incisional Hernia
Diarrhea
Blood in stool
Change in Bowel Habits
Constipation
Irritable Bowel

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Colitis
Crohn’s Disease
Hemorrhoids
Rectal Bleeding
Black tarry stools
Colon Polyps
Pancreatic Disease
Barrett’s Esophagus
Difficulty Swallowing
Nausea /Vomiting
Other: _____________________________________________________
_____________________________________________________
_____________________________________________________
GERD (Gastroesophageal Reflux Disease): Check any/all that apply to you:
 No GERD
 Variable symptoms
 Require only intermittent medications
 H2 blockers (pepcid, zantac) or low dose PPI (Prevacid, Prilosec, Nexium, etc)
 High dose PPI
 Criteria for or history of anti-reflux surgery
Gallstones: Check any/all that apply to you:
 No Gallstones
 Asymptomatic (stones present)
 Intermittent symptoms
 Severe symptoms, previous cholecystectomy
 Immediate GB surgery prior to weight loss surgery
 Previous cholecystectomy with unresolved complications
Liver Disease: Check any/all that apply to you:
 No Liver Disease
 Mild hepatomegaly, normal LFT’s, cat. 1 fatty liver
 Mod. hepatomegaly, altered LFT’s, cat. 2 fatty liver
 Marked hepatomegaly, cat. 3 fatty liver, mild fibrosis
 NASH, cirrhosis, hepatic dysfunction
 Failure, need for or previous transplant
Cardiac
Hypertension: Check any/all that apply to you:
 No Hypertension
 Borderline HTN
 Positive diagnosis
 Controlled with single medication
 Multiple Medications
 Poorly Controlled
Angina: Check any/all that apply to you:
 No Angina
 Angina with extreme exertion
 Angina with moderate exertion
 Angina with minimal exertion
 Unstable Angina
 Previous MI by history or work-up
Congestive Heart Failure: Check any/all that apply to you:
 No CHF
 Class I – exertion only
 Class II – ordinary activity
 Class III – minimal activity
 Class IV – at rest
Peripheral Vascular Disease: Check any/all that apply to you:
 No PVD
 Asymptomatic with bruit
 Claudication, anti-ischemic meds
 Transient ischemic attack, rest pain
 Previous procedure for PVD
 Stroke, loss of tissue
Deep Venous Thrombosis: Check any/all that apply to you:
 No Previous DVT
 Resolved with medications
 History of recurrent DVT’s
 Previous PE
 History of recurrent PE’s
 Has Vena Cava Filter
Cardiac (continued):
Ischemic Heart Disease: Check any/all that apply to you:
 No IHD
 Abnormal EKG
 History of MI/anti-ischemic meds
 Previous CABG/catheterization
 Active ischemia
Lower Extremity Edema: Check any/all that apply to you:
 No edema
 No treatment
 Treatment
 Stasis ulcers present
 Disability, hospitalization
Please check any/all that apply to you:






Pacemaker
Rapid Heart Rate
Varicose Veins
Heart Murmur / Atrial Fibrillation
Irregular / Skipped heart beats
Rheumatic fever / Valve Damage / MVP
Other: ______________________________________________________
______________________________________________________
______________________________________________________
Constitutional: Please check any/all that apply to you:



Fevers
Chills
Night Sweats



Anemia
Hair Loss
Fatigue



Weight Gain
Insomnia
Appetite Change
Other: _______________________________________________________
_______________________________________________________
Head and Neck: Please check any/all that apply to you:





Wears Contacts / Glasses
Blurred / Double Vision
Glaucoma
Hearing Problems
Chronic Allergies





Sinus Drainage
Dentures (partial/full)
Ear Infections
Nose Bleeds
Hoarseness