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:___________________________________________________________________
Continues next page
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. _________________________________________________________________________________________
Continues next page
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. __________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Continues next page
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
Continues next page
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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