Bariatric Surgery Medical History Questionnaire

Medical History Questionnaire Johns Hopkins Center for Bariatric Surgery

Online Information Session In-Person Information Session

Surgeon Preference: Michael Schweitzer, M.D. Thomas Magnuson, M.D. Hien Nguyen, M.D. Gina Adrales, M.D. Alisa Coker, M.D. Katherine Lamond, M.D. (Sibley Memorial Hospital)

1 Personal Information

Name: _______________________________________ Sex: ______________ Date of Birth: ____/____/_____ Mother's Maiden Name: __________________________ Address: ______________________________________ City: _________________________________________ State: ______________ ZIP code: ________________ Employer Name: _______________________________ Employment Status: _____________________________ What type of work do you do? _____________________ Emergency Contact: _____________________________ Relationship: ___________________________________ Emergency Contact Phone: ___( _____) _____-___________ Religion: ______________________________________

Example: mm/dd/yyyy

Today's Date: _________/____/__________U_se_th_r_ou_g_ho_u_t ___ Country of Birth: _______________________________ Home Phone: ___( ____)______-_____________________ Work Phone: ___( ____)______-_______E_xt_. ____________ Mobile Phone: __( ____)______-_____________________ Email Address: _________________________________ _____________________________________________ Preferred Method of Communication: ________________ Preferred Language: _____________________________ Needs Interpreter? ______________________________ Marital Status: _________________________________ Ethnicity: ____________________________________ Race: ________________________________________

2 Insurance Information

Primary Insurance: ______________________ Policy No.: _____________________ Group: __________________ Subscriber's Full Name: _________________________ DOB: _____/ ___/_______ SSN:_________-______-________ Relation to Insured: ___________________________ Subscriber's Employer Name: __________________________ Subscriber's Employment Status:___________________________________________________________________

Secondary Insurance: ______________________ Policy No.: _____________________ Group: ________________ Subscriber's Full Name: _________________________ DOB: _____/ ___/_______ SSN: ________-______-________ Relation to Insured: ___________________________ Subscriber's Employer Name: __________________________ Subscriber's Employment Status:___________________________________________________________________

Additional insurance policy? _________________________________ If yes, please provide the following information.

Additional Insurance: ______________________ Policy No.: _____________________ Group: ________________ Subscriber's Full Name: _________________________ DOB: _____/ ___/_______ SSN: ________-______-________ Relation to Insured: ___________________________ Subscriber's Employer Name: __________________________ Subscriber's Employment Status:___________________________________________________________________

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Johns Hopkins Center for Bariatric Surgery, Johns Hopkins Bayview Medical Center 4940 Eastern Ave., A Building, 3rd Floor, Baltimore, MD 21224

Phone: 410-550-0409 Fax: 410-550-1822 Website: jhbmc/bariatrics Return this completed form via Fax to 410-550-1822 or Email to bariatrics@jhmi.edu

Medical History Questionnaire (continued)

page 2

3 Provider

Name

Address (Second line if needed)

Phone

Primary Care: ___________________________________________________________________(_____)______- ______

____________________________________________________________________________________________ Cardiologist: __________________________________________________________________( _____) _____-______

____________________________________________________________________________________________ Pulmonologist: ________________________________________________________________( _____) _____-______

____________________________________________________________________________________________ Gastroenterologist: _____________________________________________________________( _____) _____-______

____________________________________________________________________________________________ Gyn/Ob: ____________________________________________________________________( _____) _____-______

____________________________________________________________________________________________ Orthopaedist: _________________________________________________________________( _____) _____-______

____________________________________________________________________________________________ Endocrinologist: _______________________________________________________________( _____) _____-______

____________________________________________________________________________________________ Psychiatrist/Psychologist: _________________________________________________________( _____) _____-______

____________________________________________________________________________________________ Pharmacy: ___________________________________________________________________( _____) _____-______

____________________________________________________________________________________________ Hematologist: _________________________________________________________________( _____) _____-______

____________________________________________________________________________________________

4 Allergies

Please list all known medications allergies with reactions (e.g., rash, difficulty breathing, etc.): Surgical tape: Yes NoLatex: Yes NoIodine: Yes No Food allergies: Yes No Other: ______________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

5 Current Medications - Attach separate list if needed.

Estrogen or Birth Control: No Yes Blood thinning medication: No Yes

Name

Dosage

Frequency

Indication

1. _________________________________________________________________________________________

2. _________________________________________________________________________________________

3. _________________________________________________________________________________________

4. _________________________________________________________________________________________

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Medical History Questionnaire (continued)

page 3

Name

Dosage

Frequency

Indication

5. _________________________________________________________________________________________

6. _________________________________________________________________________________________

7. _________________________________________________________________________________________

8. _________________________________________________________________________________________

9. _________________________________________________________________________________________

10. _________________________________________________________________________________________

11. _________________________________________________________________________________________

12 __________________________________________________________________________________________

13. _________________________________________________________________________________________

14. _________________________________________________________________________________________

15. _________________________________________________________________________________________

6 Medical History

Do you now have, or have you ever had, any of the following illnesses or symptoms?

Coronary artery disease No Yes, year: _______ Arthritis

No Yes, year: _______

Congestive heart failure No Yes, year: _______ Rheumatoid arthritis

No Yes, year: _______

Hypertension

No Yes, year: _______ Low back pain/sciatica

No Yes, year: _______

Stroke

No Yes, year: _______ Migraine headaches

No Yes, year: _______

Elevated cholesterol

No Yes, year: _______ Cancer

No Yes, year: _______

Elevated triglycerides

No Yes, year: _______ GERD/reflux

No Yes, year: _______

Hepatitis

No Yes, year: _______ Stomach ulcer

No Yes, year: _______

Thyroid disease

No Yes, year: _______ History of blood clots

No Yes, year: _______

Diabetes mellitus

No Yes, year: _______ Received a blood transfusion No Yes, year: _______

Asthma

No Yes, year: _______ Deep vein thrombosis

No Yes, year: _______

Shortness of breath

No Yes, year: _______ Menstrual irregularities

No Yes, year: _______

COPD

No Yes, year: _______ History of bleeding w/surgery No Yes, year: _______

Sleep apnea

No Yes, year: _______ HIV/AIDS

No Yes, year: _______

Liver disease

No Yes, year: _______ Urinary incontinence

No Yes, year: _______

CPAP/BiPAP machine No Yes, year: _______ CPAP/BiPAP Settings: _____________________________

7 Other Past Medical History

Please list any other current or past medical conditions for which you have seen a physician, taken medications or been hospitalized. __________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

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Medical History Questionnaire (continued)

page 4

8 Past Surgical History

Abdominal exploration

No Yes, year: _______

Appendectomy

No Yes, year: _______

Bowel resection

No Yes, year: _______

Hernia repair

No Yes, year: _______

Cholecystectomy

No Yes, year: _______

Operation for reflux

No Yes, year: _______

Cesarean section

No Yes, year: _______

Tubal ligation

No Yes, year: _______

Hysterectomy

No Yes, year: _______

Oophorectomy

No Yes, year: _______

Joint replacement

No Yes, year: _______

Type: _____________________________________

Knee arthroscopy

No Yes, year: _______

Back surgery/laminectomy No Yes, year: _______

Breast biopsy

No Yes, year: _______

Mastectomy

No Yes, year: _______

Heart angioplasty/stents No Yes, year: _______

Heart catheterization

No Yes, year: _______

Other heart procedure

No Yes, year: _______

Type: _____________________________________

Cancer surgery

Yes, year: _______

Type: _____________________________________

9 Previous Weight Loss Surgery

No Yes, year: ______________________________ Procedure: ____________________________________ Laparoscopic or open? ____________________________ Surgeon: _____________________________________ Total weight loss: ________________________________ ** Please provide a copy of the operative report **

10 Other Past Surgical History

Other: _______________________________________________________________ Other: _______________________________________________________________

Yes, year: ____________ Yes, year: ____________

11 Past Anesthesia History

Please list any difficulty with anesthesia, including airway problems. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

12 Family History

Please indicate which family members, if any, have/had the following:

Mother

Father

Sister

Obesity Anemia Bleeding tendency Blood disorder Heart disease Stroke High cholesterol High blood pressure

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Brother

Yes Yes Yes Yes Yes Yes Yes Yes

Daughter

Son

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

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Medical History Questionnaire (continued)

page 5

Asthma Lung disease Breast cancer Colon cancer Other cancer Arthritis Osteoporosis Thyroid disease Kidney disease Psychological issues

Mother

Father

Sister

Brother

Daughter

Son

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

13 Social History

Who will make up your support system? _____________________________________________________________

____________________________________________________________________________________________

Alcohol use: Yes NoBeers/wine per week:

Shots of liquor per week:

Drug use:

Marijuana:

Yes No If yes, year? ___________________________________

Recreational drugs:

Yes No If yes, year? __________ type: _____________________

Intravenous drugs:

Yes No If yes, year? __________ type: _____________________

Tobacco use:

Yes No Packs/day:

Do you currently use tobacco?

Yes No

If you no longer use tobacco, what year did you quit?

14 Weight Loss History--Expectations

Current weight: _________ Current height: __________ Highest weight: ________________________________ Lowest weight: _________________________________ How many years have you been overweight? ___________

How long have you been contemplating weight loss surgery? ______________________________________ Which procedure are you interested in? _______________ What are your weight loss goals? ____________________ How did you hear about this program? _______________

15 Diet Plan History

Please indicate which diet plan(s), medication(s) or other therapies you have attempted in the last five years.

Dates (yyyy to yyyy)

Programs/Medications

Max. Weight Lost

_________to__________________________________________________________

_________to__________________________________________________________

_________to__________________________________________________________

_________to__________________________________________________________

_________to__________________________________________________________

Provider/Dietitian Supervised?

Yes No Yes No Yes No Yes No Yes No Continues next page

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page 6

16 Health Screening History

Date of last mammogram: ___________/ ___/__________ Date of last Pap smear: ______________/ ___/__________ Date of last colonoscopy: ____________/ ___/__________ Date of last endoscopy: ______________/ ___/__________

Result: _______________________________________ Result: _______________________________________ Result: _______________________________________ Result: _______________________________________

17 Mental Health History

Have you ever been treated for depression?

No Yes, year: _____________________________

Have you ever been hospitalized for mental illness?

No Yes, year: _____________________________

Are you currently in treatment?

No Yes

Psychiatrist name:______________________________________________________________________________ Address: __________________________________________________________ Phone _(_____)______-______

Psychologist name: _____________________________________________________________________________ Address: __________________________________________________________ Phone _(_____)______-______

18 Gynecological/Obstetric History

Number of pregnancies: ___________________________ Date of onset of menses: ___________________________ Last normal menstrual period: ______________________

Number of deliveries: _____________________________ Date of onset of menopause:________________________ Current method of birth control: ___________________

19 Review of Systems

Please indicate any of the following that you have experienced either currently or in the past

Cardiovascular Abnormal heartbeats Chest pain Cold feet Heart attack Heart murmur Heart pounding High blood pressure Loss of pulse Low blood pressure Pain in arms Pain in legs Pain in neck Palpitations Stroke

Constitutional Abnormal bleeding Fatigue Night sweats Recent weight loss Tiredness

Endocrine Adrenal gland tumor Diabetes Goiter Hyperthyroid Low thyroid Previous radiation Previous steroid use Swollen glands Sneezing

Sore throat Vertigo Gastrointestinal Abdominal pain Blood in stool Change in stool size Cirrhosis Colitis Constipation Diarrhea Heartburn/reflux Hemorrhoids Hepatitis Irritable bowel Jaundice Nausea

Pain with bowel movement Vomiting Genitourinary Abnormal Pap smear Abnormal vaginal bleeding Abnormal vaginal discharge Bladder infection Blood in urine Frequent urination Irregular periods Kidney infection Kidney stones Leakage of urine Loss of erection

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Medical History Questionnaire (continued)

page 7

Pain with urination Penile discharge Trouble starting urination Vaginal discharge Head and Neck Blurred vision Difficulty swallowing Dizziness Double vision Hoarseness Loss of hearing Loss of vision Loss of smell Lump in neck Runny nose Sinus congestion Sinus infections Musculoskeletal Abnormal lumps or masses

Ankle pain Arthritis Foot pain Herniated disc Hip pain Joint pain Knee pain Low back pain Muscular aches Numbness in feet or legs Sciatica Swelling of joints Neurological Convulsions Fainting Falling Lightheadedness Loss of consciousness Muscle weakness Numbness

Seizures Tremors Psychological Anorexia Anxiety Binge eating Bulimia Depression Hospitalization for emotional problems Nervousness Psychiatric or psychological counseling Schizophrenia Suicidal thoughts Suicide attempts Respiratory Asthma Awakening at night Bloody sputum Bronchitis

Cough Difficulty sleeping flat Emphysema Irritability Morning headaches Observed apnea spells/ stop breathing Pneumonia Shortness of breath Snoring Waking at night short of breath Wheezing Skin/Breast Abnormal mammogram Abnormal moles Breast mass Burns Nipple discharge Rash Skin cancer

20 Sleep History

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

Situation

Sitting and reading Watching TV Sitting inactive in a public place (e.g., theater or a 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

Chance of Dozing

__________ __________ __________ __________ __________ __________ __________ __________ Total: __________

Johns Hopkins Center for Bariatric Surgery, Johns Hopkins Bayview Medical Center 4940 Eastern Ave., A Building, 3rd Floor, Baltimore, MD 21224

Phone: 410-550-0409 Fax: 410-550-1822 Website: jhbmc/bariatrics Return this completed form via Fax to 410-550-1822 or Email to bariatrics@jhmi.edu

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