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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