Dear Patient:



Dear Patient:

Thank you for inquiring about our weight loss surgery program! The decision to undergo weight loss surgery is not a decision you made quickly; in a similar fashion, the process of preparing you for surgery also cannot occur quickly, nor be rushed. Please take the time to fill out the enclosed intake form carefully and completely. Remember to attach a legible copy of your picture ID along with your medical insurance card (front & back). Our staff will then contact you to give you an appointment date, usually within two weeks of receipt of your application.

In the meantime, we encourage you to attend our informational seminars, which we hold at Sinai Hospital’s Zamoiski Auditorium and Northwest Hospital Pike Conference Room. We will be present at each seminar, as well as, members from our staff and post-op patients. Everyone is invited to attend, be sure to verify the dates on our website () or call 1-866-404-DOCS (3627).

Most insurance companies require that policy holders be seen monthly for 3-6 consecutive months to document weight loss attempts and progress. Therefore, as an insurance and program requirement, we require patients to see the Registered Dietitian at Sinai Hospital, Northwest Hospital, or Dorsey Hall location in Columbia. Adherence to the program greatly increases your success following bariatric surgery. All program locations adhere and teach the same nutritional information concerning food choices and surgery.

Prior to being seen at one of the LifeBridge Health centers, ask your Primary Care Physician (PCP) for a request for consultation. If a referral is required with your insurance plan, please make sure we have an updated referral on file. All co-payments are due at the time of service. PLEASE NOTE we only accept cash, Visa, and/or MasterCard for payment at Sinai and Northwest Hospital locations. We only accept cash or checks at our other locations.

Your insurance plan will likely require extensive testing to ensure that they will approve the surgery. If you prefer, you can obtain some of this BEFORE your initial consultation. The following are required by ALL insurance companies of all patients prior to scheduling surgery:

1) Proof of attendance at a minimum of one of our bariatric seminars.

2) A letter from your primary care physician. This letter should summarize your diet history, your obesity-related medical problems and any physician-supervised weight loss attempts that you have had. It should also include a sentence or two stating that your physician feels that you are a good candidate to undergo surgery.

3) Psychology/psychiatry clearance: all patients are required to undergo a psychological evaluation prior to surgery, so that we can document adequate knowledge of the procedure, reasonable weight loss expectations, and the ability to comply with the rigorous dietary restrictions post-operatively. You can obtain clearance from your own psychologist or psychiatrist if you prefer.

Every patient will require additional pre-operative testing, but these tests will be ordered on an individual basis after you have met with one of the surgeons. If you have any questions about the Bariatric Surgery Program at Sinai Hospital, please contact us at 410 601-4486 and one of our staff will be glad to help you.

We look forward to meeting you and helping you reach your goal of a healthy weight and healthier lifestyle.

Christina Li, MD, FACS Celine Richardson, MD, FACS

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AVOID these medications 2 weeks prior to surgery and call the office before taking any new medication for pain management

|Aspirin Products: |Aspirin Products: |NSAIDS products: |

|Aggrenox |Ecotrin |Diclofenac (Flector, fcatafrlam, Voltaren, Arthrotec,|

|Alka-Seltzer |Endodan |Cataflam, Cambia) |

|Anacin |Equagesic |Disflunisal (Dolobid) |

|Ascriptin |Excedrin |Etodolac (Lodine) |

|AsperDrink |Gelprin |Fenoprofen (Nalfon) |

|Aspergum |Genacote |Flurbiprofen (Ansaid) |

|Aspirin/Butalbital/Caffeine |Goody’s Halfprin |Ibuprofen (Advil, Motrin, Genpril, Haltran, Menadol, |

|Aspirin with buffers |Orphenadrin P-A-C |Midol, Vicoprofen, Dristan) |

|Aspirtab |Magnesium Salicylate |Indomethacin (Indocin) |

|Aspir-Trin |Magnaprin |Ketoprofen (Oruvail, Orudis) |

|Bayer |Micrainin |Ketorolac (Toradol, Acular, Acuvail, Sprix) |

|BC Powder |Miniprin |Meclofenamate |

|Bismuth Subsalicylate (Pepto Bismol, Kaopectate, |Norgesic (Forte) |Mefenamic (Ponstel) |

|Bismatrol, Kola-Pectin, Diotame, Kapectolin, Bismate,|Norwich Aspirin |Meloxicam (Mobic) |

|Bismakote, Bismuth, Stomach Relief, Kao-Tin, Kensorb,|Pamprin |Nabumetone (Relafen) |

|Kao-Paverin, Peptic Relief, Sootheze). |Percodan |Naproxen (Naprosyn, Prevacle Napra PAC, Aleve, |

|Bufferin |Robaxisal |Naprelan, Anaprox) |

|Butalbital |Soma |Oxaprozin (Daypro) |

|Carisoprodol Compound |St. Joseph’s Aspirin |Piroxicam (Feldene) |

|Citrated/Aspirin/caffeine |Synalgos-DC |Salsalate (Disalcid, Amigesic, Salflex, Persistin, |

|Cope |Trilisate |Mono-gesic, Marthritic, Arthra-G, Argesic-SA) |

|Damason-P |Vanquish |Sulindac (Clinoril) |

|Easprin |Zorprin |Tolmetin (Tolectin) |

|Fiorinal | | |

| |Store brands: Good Neighbor Pharmacy, Good Sense, |Cox-2 Inhibitors |

| |Leader, Medi-First, Quality Choice, Top Care, Rite |Celecoxib (Celebrex) |

| |Aid, etc. | |

****KEEP THIS PAGE***

Application Process

1. Call your insurance company and complete the Insurance Verification form on page 4.

2. Complete the Patient Application on pages 5 - 15 and the Nutritional Assessment on pages 16 – 22.

3. Return the Insurance Verification, Patient Application, and the Nutritional Assessment to our office (pages 4 – 18).

a. Please keep the folder & resource papers in the right sleeve.

4. Our office staff will verify your insurance benefits.

5. One of the physicians will review your application.

6. Our office staff will call you to schedule an initial appointment with the physician and dietitian.

a. Reminder: the nutritional consultation has a mandatory program fee (not covered by any insurance) which is due at the initial appointment.

b. All self-pay portions are due at the time of service.

c. We accept only cash or credit cards as payment. We do not accept checks.

7. Please allow 1-2 weeks, plus mailing time for our staff to contact you.

8. While waiting to hear from our office you can complete the following steps:

a. Contact your Primary Care Physician for any necessary referrals per your insurance requirement. (Some offices require 1-2 weeks notice to have referrals ready).

b. Attend one of our bariatric seminars (see enclosed flyer for dates).

PLEASE INCLUDE COPY OF DRIVER’S LICENSE AND INSURANCE CARD (FRONT & BACK) WITH APPLICATION!

Additional Information

• HMO'S, POINT OF SERVICE, AND MANAGED CARE PLANS:

If your insurance company is an HMO, point of service, or managed care plan, you must obtain a written out-of-network referral before your consult with the surgeon. You must follow the rules of your insurance company in order to obtain the highest level of benefits. Your primary care physician's office will need to contact the insurance company for a referral. You may make an appointment with the surgeon; however, the referral must be received or brought with you to the appointment.

• SELF PAY PATIENTS:

If your insurance does not cover gastric bypass surgery and you wish to proceed as a cash patient, please contact the office for fees and scheduling information.

• PROGRAM FEE:

A program fee is required at your initial appointment. This fee is non-refundable and covers 1 year of unlimited visits or consultations with the nutritionist.

• PAIN MEDICINE:

Do not take any “pain medication/anti-inflammatories” three weeks prior to surgery without consulting with your surgeon (see list on page 2). Most pain medicines increase the chance of bleeding. This may result in cancellation of your procedure.

IMPORTANT NOTICES

We only accept cash or credit card as acceptable form of payment.

We require 24 hour notice if you are unable to keep your scheduled appointment. A fee of $25 will be billed to you for each missed appointment.

Insurance Verification Form

Call to verify insurance coverage for bariatric surgery. The telephone number is located on the back of your insurance card. This completed form must be submitted with your application.

|First Name: | |Middle Initial: | |

|Last Name: | |Birth Date: | |

|Insurance Company: | | |

|Insurance Phone No.: | | |

|Date Insurance Company Called:_____________________ |Spoke with:__ ___________________ |

|Type of Plan: ( HMO |( POS |( PPO |

|Ask your insurance representative the following questions: |

|Is this a small group policy? |( Yes ( No |

|Does this policy have ANY exclusion for Bariatric Surgery or Morbid Obesity? |( Yes ( No |

|Does the insurance cover the following procedures: |( Yes ( No |

|Gastric Bypass (CPT 43644) |( Yes ( No |

|Gastric Banding (CPT 43770) |( Yes ( No |

|Sleeve Gastrectomy (CPT 43843) | |

|Is this procedure subject to any pre-existing conditions on the policy? If yes, please list |( Yes ( No |

|_______________________________________________________ | |

|Are there specific criteria that need to be met in order to qualify for this surgery? If yes, please list: |( Yes ( No _____ months |

|Total months of consecutive supervised weight loss | |

|Other: __________________________________________ | |

|Do you need a referral from your Primary Care Physician to see a Specialist? |( Yes ( No |

|Is there a co-pay to see the surgeon? |( Yes ( No |

|What is the co-pay? |$ ___________ |

|Do you have a deductible? |( Yes ( No |

|What is the amount? | |

|How much of the deductible has been met? | |

| |$ ___________ |

| |$ ___________ |

|Please include a copy of your driver’s license and insurance card (front & back) with the application |

Patient Application

NAME: _________________________________ Date: __________________

| |

|I am interested in seeing: |

|I am interested in having: |

| |

|What is your preferred location? |

| |

| |

|Dr. Christina Li |

| |

|Gastric Bypass |

| |

|Northwest |

| |

| |

|Dr. Celine Richardson |

| |

|Laparoscopic Band |

| |

|Sinai |

| |

| |

| |

| |

|Sleeve Gastrectomy |

| |

|Ellicott City |

| |

|Social Security No.: | |

|First Name: | |Middle Initial: | |

|Last Name: | |Gender: |M ( F ( |

|Applicant’s Maiden Name: | | |

|Birth Date: | |Current Age: | |

|Weight: | | |

Insurance Information:

| |Primary Insurance | |Secondary Insurance |

|Insurance Carrier Name: | | | |

| | | | |

|Group Number: | | | |

|ID Number: | | | |

|Policyholder’s Name: | | | |

|Policyholder’s DOB: | | | |

|Policyholder’s SS#: | | | |

|Relationship to Insured: | | | |

|Insurance Address: | | | |

|City, State, Zip: | | | |

|Phone Number: | | | |

|Fax Number: | | | |

NAME: _________________________________

Contact Information:

|Home Address: | | |

|City: | |Sta|

| | |te:|

| | |May we contact you at this number? | |

|Home Number: | |Yes ( |No ( |Preferred ( |

|Employer: | |Occupation: | |

|Employers Address: | | |

| | | |

|Length of time @ current employment: ________ Years ________ Months | |

Emergency Contact Information:

|Name: | |Relationship: | | |

|Home Address: | |City, State, Zip: | | |

|Home Number: | |Cell Number: | | |

|Work Number: | | | | |

Pharmacy Information:

|Pharmacy Name: ______________________ |Phone Number: ________________________ |

|Location: ______________________________ |Fax Number: ___________________________ |

|( Family/Friend |( Magazine |( TV |

|( Insurance |( Newspaper | |

|( Internet |( Primary Care Physician |( Other: ________________ |

I heard about LifeBridge Health Bariatric through:

NAME: ________________________________

| |Primary Care Physician | |Other Physician | |

|Name: | | | | |

|Specialty: | | | | |

|Address: | | | | |

|Address 2: | | | | |

|City: | | | | |

|State: | | | | |

|Zip: | | | | |

|Phone Number: | | | | |

|Fax Number: | | | | |

Physician Information:

Social History:

|Marital Status: |Ethnic Origin: |Education: |Number of Children: |

|( Single |Black/African American |9 to 11 years |None |

|Married |Hispanic |High School Graduate |1 |

|Divorced |White/Caucasian |Vocational/Technical |2 |

|Separated |Asian/Oriental |Attended College |3 |

|Widowed |Other: |College Graduate |4 |

| | |Post Graduate Degree |5 or more |

|Religion: |Do you currently or have you ever use/d tobacco |Yes ( No ( |

|Atheist |products? |If yes, how much: |

|Catholic |If yes, what kind: |( 1/2 pack or less per day |

|Jehovah Witness |Cigarettes |Between 1 – 1.5 packs per day |

|Jewish |Cigars |Between 1.5 – 2 packs per day |

|Presbyterian |Chewing tobacco |2 packs or more per day |

|Other: | | |

|Do you drink alcohol? Yes ( |No ( |Do you use illegal drugs? Yes( |No ( |

|If yes, how much: |If yes, how often: |If yes, what kind: |If yes, how often: |

|Less than 2 per day |Daily |Marijuana |Daily |

|Between 2 – 5 per day |Weekly |Cocaine |Weekly |

|Between 6 – 10 per day |Monthly |Heroin |Monthly |

|More than 11 per day |Occasionally |Amphetamines |Occasionally |

| |

|List the diets/programs have you tried within the last 5 years: |

|Diet or Weight Loss Medication |Year |Length in Months |Number of Pounds Lost |

| | | | |

|What age were you considered obese? |

|What was your lowest adult weight? |

|What is your desired weight? |

Check if you have used the following medications to lose weight:

|Phentermine |Orlistat (Xenical) |B-12 shots |

|Phen-Fen |Meridia |Other |

Check the eating behaviors which have contributed to weight gain:

|Skipped meals |Frequent sweets |Vomiting after large meals |

|Large portions |High carbohydrate diet |Frequent snacking |

|Fatty foods |Binge eating |Fast foods |

|Emotional eating |Laxative use |Other: |

NAME: _________________________________

Drug Allergies: ( Check if no allergies

|Medication Allergies |Type of reaction |

| | |

| | |

| | |

| | |

| | |

Current medication (prescription and non-prescription): ( Check if no medications

|Medication |Strength |Frequency |

|Arthritis |Fibromyalgia |Pneumonia |

|Asthma |Heart Attack |Pulmonary Embolism |

|Bronchitis |High blood pressure |Reflux Disease |

| | |(Heartburn or severe indigestion) |

|Cancer |Hypercholesterolemia |Seizure |

| |(High cholesterol) | |

|Cardiac Surgery |Hypertriglyceridemia |Sleep Apnea |

| |(High triglycerides) |Diagnosed( Observed( |

|Chest Pain |Hyperthyroidism |Snore |

|CHF |Hypothyroidism |Stress Incontinence |

|Depression |Leg Ulcers |Stroke |

|Diabetes Type I |Lower back pain |Varicose Veins |

|(Insulin dependent) | | |

|Diabetes Type II (Non-Insulin Dependent) |Migraines/Headache |Other: |

Surgical History (α all that apply): ( Check if no surgical history

|Surgery |Date |Comment |

|C section | |Number: |

|Gall Bladder | |( Open |( Laparoscopic | |

|Tubal Ligation | | |

|Other (list surgeries and year) : |

|Hospital Admissions: |

NAME: _________________________________

Family History:

| |Alive |Age |Health Problems |

| | |(Current or at | |

| | |death) | |

|Mother |( Yes ( No | |Heart Disease |Stroke |

| | | |Diabetes |Cancer |

| | | |Blood clots |Overweight/obese |

| | | |Other: | |

|Father |( Yes ( No | |Heart Disease |Stroke |

| | | |Diabetes |Cancer |

| | | |Blood clots |Overweight/obese |

| | | |Other: | |

|Maternal Grandmother |( Yes ( No | |Heart Disease |Stroke |

| | | |Diabetes |Cancer |

| | | |Blood clots |Overweight/obese |

| | | |Other: | |

|Maternal Grandfather |( Yes ( No | |Heart Disease |Stroke |

| | | |Diabetes |Cancer |

| | | |Blood clots |Overweight/obese |

| | | |Other: | |

|Fraternal Grandmother |( Yes ( No | |Heart Disease |Stroke |

| | | |Diabetes |Cancer |

| | | |Blood clots |Overweight/obese |

| | | |Other: | |

|Fraternal Grandfather |( Yes ( No | |Heart Disease |Stroke |

| | | |Diabetes |Cancer |

| | | |Blood clots |Overweight/obese |

| | | |Other: | |

|Sibling |( Yes ( No | |Heart Disease |Stroke |

|( Brother | | |Diabetes |Cancer |

|( Sister | | |Blood clots |Overweight/obese |

| | | |Other: | |

|Sibling |( Yes ( No | |Heart Disease |Stroke |

|( Brother | | |Diabetes |Cancer |

|( Sister | | |Blood clots |Overweight/obese |

| | | |Other: | |

|Sibling |( Yes ( No | |Heart Disease |Stroke |

|( Brother | | |Diabetes |Cancer |

|( Sister | | |Blood clots |Overweight/obese |

| | | |Other: | |

|HEAD AND NECK |Change in vision |Ringing in ears |Nosebleeds |

|N/A | | | |

| |Double vision |Dizziness |Hoarseness |

| |Deafness |Sinusitis |Other |

|CARDIOVASCULAR |Palpitation |Leg pain w/ walking |High cholesterol |

|N/A | | | |

| |Chest Pain |Heart disease |Other |

| |Shortness of breath |History of heart attack | |

|RESPIRATORY |Cough |Asthma/Bronchitis |Shortness of Breath |

|N/A | | | |

| |Wheezing |Sleep Apnea |Other |

| | |Diagnosed ( Observed ( | |

|GASTROINTESTINAL |Loss of appetite |Abdominal pain |Changes in bowel habits |

|N/A | | | |

| |Difficulty w/ swallowing |Vomiting |History of blood transfusion |

| |Nausea |Bloody Stools |History of polyps |

| |Belching/ Excess Gas |Jaundice |Other |

|URINARY |Difficulty urinating |Stress incontinence |Other |

|N/A | | | |

| |Urinating at night |Kidney stones | |

|ORTHOPEDICS |Back pain |Itching |Seizures |

|N/A | | | |

| |Arthritis |Change in hair |Difficulty walking |

| |History of fractures |Weakness |Other |

| |Body Aches |Numbness or tingling | |

|PSYCHIATRIC |Panic attacks |Sleeping difficulties |Bipolar disorder |

|N/A | | | |

| |Chronic depression |Attempted suicide |Other |

|ENDOCRINE |Thyroid Problems |Hair Loss |Other |

|N/A | | | |

| |Menstrual Problem |Diabetes | |

| | |Insulin ( Non-Insulin ( | |

|HEMATOLOGY |Anemia |Enlarged lymph nodes |Other |

|N/A | | | |

| |Bleeding |History of cancer | |

|ALLERGIES |Eczema |Hay fever |Asthma |

|N/A | | | |

NAME: _________________________________

Health History (α all that apply):

Nutritional Assessment

NAME: _________________________________

Complete the following questions. Please fill out as honestly and as with much detail as possible. Turn this in with your application.

Please list any food or drink with calories you have consumed in the past 24 hours:

|Meal |Time |Place |What & how much |

|Breakfast | | | |

|Snack | | | |

|Lunch | | | |

|Snack | | | |

|Dinner | | | |

|Snack | | | |

1. What kinds of beverages do you drink and how much? How often?

| |How often per day/week |How much (ounces) |

|Regular Coffee/Tea | | |

|Decaf Coffee/Tea | | |

|Regular Soda | | |

|Diet Soda | | |

|Juice | | |

|Other drinks with Sugar | | |

2. How many meals do you eat away from home on weekdays?

Breakfast _____________ Lunch_____________ Dinner_____________

3. How many meals do you eat away from home on the weekends?

Breakfast _____________ Lunch_____________ Dinner_____________

4. Do you currently take vitamins or minerals? □ Yes □ No If yes, list the names and amount you take:_____________________________________________________________

5. Do you have any food allergies □ Yes □ No If yes, which foods and type of allergic reaction?_________________________________________________________________

6. Do you have any food intolerance? □ Yes □ No If yes, please circle which food causes intolerance?

Lactose Spicy Acidic Caffeine MSG Sugar Substitute Other_____________________________________________________________________________

7. Do you use sugar substitutes? □ Yes □ No If yes, which one?_________________

8. What do you do for a living and how many hours do you work per week?_________

9. Do you travel for your career? □ Yes □ No If yes, how often?________________

10. Marital Status: □ Single □ Married □ Divorce Number of children?________

11. Who prepares the meals in your home?________________________________________

12. Who does the grocery shopping?______________________________________________

13. Are there any religious, ethnic, or cultural factors affecting food choice? □ Yes □ No If yes, please elaborate__________________________________________________

14. Are the meals cooked in the home low far?

□ All the time □ Sometimes □ Never

15. Do you eat fried, stir fried, or sautéed foods cooked at home? □ Yes □ No If yes, how often and which type?___________________________________________________

16. What kind of fats do you use for frying and sautéing at home? □ Butter

□ Margarine □ Olive Oil □ PAM type spray □ Shortening or Lard

□ Other:________________________________________________________________________

17. What kind of spreads do you use for bread? □ Reduced calorie margarine

□ Maragrine □ Butter □ Other:_______________________________________________

18. What is the food/drink that you will have the hardest time giving up? _______________________________________________________________________________________

19. Describe frequent cravings_________________________________________________________

______________________________________________________________________________________

20. Do you wake up in the middle of the night hungry? □ Yes □ No If yes, how often?____________________________________________________________________________

21. Do you remember what you eat? □ Always □ Sometimes □ Never

22. List the restaurants where you often eat:________________________________________

____________________________________________________________________________________________________________________________________________________________________

23. Do you eat when you are? □ Bored □ Happy □ Sad □ Stressed

24. Do you ever binge on food until you are uncomfortable or ill? □ Yes □ No If yes, how often?___________________________________________________________________

25. Do you drink alcohol? □ Yes □ No If yes, how many at a time and how often? ___________________________________________________________________________

26. Do you smoke? □ Yes □ No If yes, how many cigarettes a day?_____________

27. Do you exercise now? □ Yes □ No If yes, what exercise do you do and how often do you exercise?____________________________________________________________

28. Is there any reason why you cannot exercise or should not exercise?_________________________________________________________________________

29. Has your weight changed in the past year? □ Yes □ No If so, how much have you gain or lost? ____________________________________________________________

30. What do you think is a realistic weight for you?__________________________________

|List the diets/programs you have tried in the last 5 |Year |Length in Months |Number of Pounds Lost |

|years: diet or weight loss medication | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

31. Have you had a previous weight loss surgery? □ Yes □ No If yes, list the date the surgery was performed, which procedure was done, and where the procedure was performed.________________________________________________________

32. What kind of education were you given with the previous weight loss surgery?

____________________________________________________________________________________________________________________________________________________________________

33. Do you use any meal replacement products (liquids, bars, protein shakes)? □ Yes □ No If yes, how often and which one?________________________________________

34. Do you use any other dietary supplements on a regular basis? □ Yes □ No

□ Black Kohash □ DHEA □ Fiber powders/tablets □ Fish or Flaxseed oil

□ Garlic pills □ Glucosamine Chondrontin □ Herbs □ Premarin

Amounts:___________________________________________________________________________________________________________________________________________________________

35. Have you had any history with eating disorders? Such as binge eating and then vomiting or not eating or eating very little for long periods of time. □ Yes □ No If yes, please be specific on age/type of eating disorder/year disorder occurred/duration of disorder and circumstances that were contributing to the issue.. If you were professionally treated, how long ago was the treatment and did you receive clearance from your doctor?__________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________

36. Do you have any special needs for education material?

□ Reading problems □ Deafness □ Poor eyesight □ Other_________________

Welcome to the program I look forward to meeting with you!

Kim Visioni RD, LDN

410-701-4881 (office) 410-701-4883 (Fax)

kvisioni@

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