General information First Name Last Name Age Date of birth date of birth Email Phone Martial Status Separated Single Married Divorced Widowed Street Address City State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawái Idaho Illinois Indiana Iowa Kansas Kentucky Luisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New México New York North Carolina North Dakota Ohio Oklahoma Oregón Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Country Surgery Request Gastrict Sleve Gastric Bypass Duodenal Switch Mini Gastric Bypass Gastric Balloon - In Gastric Balloon - Out" Gastric Balloon Adjustment Lap-Band Lap-Band Removal Lap-Band Revision Revision: Gastric Sleeve to Gastric Bypass Revision: Gastric Sleeve to Duodenal Switch Revision: Gastric Sleeve to Mini Gastric Bypass Revision: RNY Gastric Bypass Undecided Date of Surgery Date of Surgery History of past illness Have you had any previous surgery? YES NO If 'yes ' please list surgeries Have you ever had any of the following: Congential abnormalities Yes No Significant hospitalization Yes No Other serious ilness Yes No Cancer Yes No Prior Surgery Yes No Chickenpox Yes No Tuberculosis Yes No Stroke Yes No Diabetes Yes No Rheumatic fever or heart disease Yes No If you have answered yes to any of the above questions, please list the details below if appropriate Medications currently taken Please list doses and the interval taken, name of medication, dose and number of times taken per day Family history Please indicate if any blood relative had any of the following conditions: Cancer No Yes Peptic Ulcer Disease No Yes Colon polyp(s) No Yes Colon diverticulosis No Yes Colitis or Crohn's Disease No Yes Pancreas disorder No Yes Liver disease No Yes Diabetes No Yes Stroke No Yes Heart trouble No Yes Bleeding tendency No Yes Arthritis No Yes Convulsions or seizures No Yes Anemia No Yes Kidney disorder No Yes Tuberculosis No Yes Please complete the following information regarding your close relatives: if deceased, please enter age at death and cause of death Father Deceased Alive Mother Deceased Alive Please enter any other important family history not listed above: Social / personal history Please indicate if any blood relative had any of the following conditions: Drinking alcohol Never Rarely Moderately How often? Smoking Never Previously smoked Presently smoking How often? Do you drink coffee? No Yes Cups per day Are you exposed to fumes, dust or solvents? No Yes What is your job/ occupation? Drugs recently taken - within the past six months Mark all the appopiate NSAID's (such as ibuprofen, naprosen. eg. Advil, Aleve, etc) Anticoagulants (such as Coumadin or Warfarin) Tranquilizers Acetominophen (such as Tylenol) Alternative or Complementary meds Diet aids, supplements or prescriptions NSAID's (such as Vioxx and Celebrex, etc) Cortisone/ Steroids/ ACTH Hypotensives (high blood pressure medicines) Aspirin Antibiotics Herbals Supplements Allergies and sensitivities Antibiotics (Allergic) Penicillin Sulfa drugs Other Narcotics Morphine Codeine Demerol Other Anesthetics Novocaine Other Analgesics Aspirin / Empirin Other Serums Tetanus antitoxin Other Foods Eggs Mils Shellfish Other Other drugs or medication System review General Height Weight BMI Recent weight change No Yes Good health in general No Yes Unknown Fevers No Yes Chills No Yes Change in appetite No Yes Gastrointestinal Change in appetite No Yes Rash No Yes Frequent infection or boils No Yes Pain with swallowing No Yes Trouble swallowing (eg. food sticks in the throat) No Yes Regurgitation of food No Yes Belching No Yes Nausea No Yes Peptic Ulcer Disease (stomach or duodenum) No Yes Vomiting food or blood No Yes Surgery to the esophagus No Yes Surgery to the stomach No Yes Surgery to the small intestines No Yes Surgery to the large intestines (colon) No Yes Bloating No Yes Abdominal pain No Yes Pain after meals No Yes Food intolerance No Yes Gall bladder disease (e.g. surgery or gallstone) No Yes Liver disease No Yes Jaundice No Yes Hepatitis No Yes Blood Transfusion No Yes Pancreas Disease No Yes Constipation No Yes Diarrhea No Yes Laxative use No Yes Black colored bowel movements No Yes Colitis No Yes Crohn's Disease No Yes Diverticulosis No Yes Polyps No Yes Recent change in bowel habits No Yes Painful bowel movements No Yes Blood in the stool No Yes Mucus in the stool No Yes Pus in the stool No Yes Fistula No Yes Hemorrhoids No Yes Anal fissures No Yes Anal pain or cramps No Yes Anal itching No Yes Bowel movements in the late night No Yes Irregular bowel movements (inability to control timing) No Yes Skin Skin Disease No Yes Jaundice No Yes Hives No Yes Rash No Yes Eczema No Yes Abnormal Pigmentation No Yes Frequent infection or boils No Yes Respiratory URI (cold) presently No Yes Spitting up blood No Yes Chronic or frequent cough No Yes Asthma No Yes Wheezing No Yes Difficulty breathing No Yes Any trouble with lungs No Yes Pleurisy No Yes Pneumonia No Yes Gynecological Gynecological Not Applicable Yes Periods Age started / year Age Duration / Days/ year Frequency (days) Pregnancies Miscarriages Date of first day of last period Endometriosis No Yes Neck Stiffness No Yes Thyroid trouble No Yes Head Eyes Ears Nose Throat Do you wear contacts? No Yes Eye disease or injury No Yes Double vision No Yes Headaches No Yes Glaucoma No Yes Itchy eyes or nose No Yes Sneezing or runny nose No Yes Nosebleeds No Yes Chronic sinus trouble No Yes Ear disease No Yes Impaired hearing No Yes Dizziness No Yes Transient episodes of unconsciousness No Yes Cardiovascular Chest pain or angina pectoris No Yes Shortness of breath with walking No Yes Shortness of breath with lying down No Yes Difficulty walking two blocks No Yes Heart trouble or heart attacks No Yes High blood pressure No Yes Swelling of hands No Yes Swelling of feet No Yes Swelling of ankles No Yes Heart murmur No Yes Awakening at night smothering No Yes Valvular heart disorder No Yes Genitourinary Frequent urination No Yes Loss of urine No Yes Night time urination No Yes Burning or painful urination No Yes Blood in the urine No Yes Kidney trouble No Yes Kidney stones No Yes Locomotor - mulculoskeletal Varicose veins No Yes Weakness of joints No Yes Any difficulty walking No Yes Claudication No Yes Arthritis No Yes Back pain No Yes Neuro - Psychiatric Ever had psychiatric care? No Yes Ever advised to see a psychiatrist? No Yes Fainting spells No Yes Convulsions No Yes Paralysis No Yes Hematologic Are you slow to heal after cuts? No Yes Blood disease No Yes Anemia No Yes Iron deficiency No Yes Iron overload No Yes Phlebitis No Yes Abnormal brusing No Yes Abnormal bleeding No Yes Thalassemia No Yes Thyroid disease No Yes Hormone therapy No Yes Change in hat or glove size No Yes Any change in hair growth No Yes High cholesterol No Yes High triglyceride No Yes Dry skin No Yes Hot intolerance No Yes Cold intolerance No Yes History of excessive bleeding (after tooth extraction or surgery) No Yes Diabetes No Yes Psychological evaluation Have you ever been in any kind of counseling or therapy? Please describe: Are you or have you ever been under a psychiatrist's care? If yes, what was your diagnosis? Have you ever participated in a support group? Please describe: Are you or have you ever taken psychiatric medications? Please describe and for what purpose: How long has excess weight been an issue in your life? What methods have you tried to lose weight? What do you hope to obtain from this surgery? What are some of the changes you want to make in your lifestyle upon having this surgery? Send Questionnaire
