Patient Health History Questionnaire - Bariatric Surgery

[Pages:11]

186 E 76th Street, 1st Floor, New York, NY 10021

212-434-3285

(PLEASE PRINT)

Patient Health History Questionnaire BARIATRIC SURGERY

The following information is very important to your health. Please take time to fully and completely fill out this important information. We are counting on you.

________________________________________ /____________________________ /_________________________ DATE: ______ /______ /__________

PATIENT: LAST NAME

FIRST

MIDDLE

_______ / ______ / _________ BIRTH DATE

________ AGE

__________ / _________ / __________ SOCIAL SECURITY NO.

___________________________________________ HOME PHONE NO.

_______________________________________________ CELL PHONE NO.

WEIGHT RELATED ILLNESSES

Have you had, or do you have, any of the following illnesses or symptoms?

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

CARDIOVASCULAR DISEASE:

Palpitations (irregular and/or forceful heartbeat)

Varicose Veins

Swelling of Ankles/Feet

Blood clot (Deep Vein Thrombosis- DVT)

Pulmonary Embolism

High Cholesterol

High Triglycerides

High Blood Pressure

Angina (chest pain)

M.I. (myocardial infarction, heart attack)

CABG (coronary artery bypass graft, known as open heart surgery)

Abnormal EKG

Shortness of breath

Stress test to rule out cardiac problems

Date:________________

Echocardiogram (heart ultrasound)

Date:________________

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DIABETES: Yes No Yes No Yes No

Diabetes Do you take Insulin Oral Medication

Yes No Yes No Yes No

ASTHMA Asthma Hospitalization in last 2 years Steroid use in last 2 years

Yes No Yes No

SLEEP APNEA SYNDROME Sleep Apnea CPAP or BiPAP Year diagnosed: ________________ Last sleep study: ________________

Yes No

HEARTBURN/ HIATUS HERNIA

Yes No Yes No Yes No

GALLBLADDER Gallbladder disease Gallbladder removed Ultrasound performed

Yes No Yes No

GENITO-URINARY: Leakage of urine with laughing/coughing/ sneezing Wear pads frequently

Yes No Yes No Yes No Yes No Exercise limitation: (CIRCLE ONE)

MUSCULOSKELETAL: Arthritis Low back strain/pain/sciatica Pain in hips/knees/ankles/feet Assistance to ambulate None / Minimal / Severe

Yes No Yes No Yes No Yes No Yes No

CANCER Breast Endometrial Uterine Prostrate

Other: ___________________________________ Treatment/Remission:________________________________

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Yes No

WEIGHT RELATED INJURIES AND TRAUMA

Yes No

VENOUS STASIS DISEASE

Yes No

COLITIS

Yes No

LIVER DISEASE

Yes No

ULCERS / GASTRITIS

Yes No

RECTAL BLEEDING

Yes No

THYROID DISEASE

Yes No

EATING DISORDER

If Yes, have you been seen by a specialist? Yes No

For female patients only Currently pregnant: Yes No Number of pregnancies: __________________ Number of live births: ___________________ Miscarriages/abortions: __________________ Obstetric complications:

Age at first period: __________________ Date of last period: _________________

___________________________________________________________________________________________________

Do you presently use: Birth control pills Estrogens

Yes No Yes No

List Type: _________________________________________ List Type: _________________________________________

Current Medications:

Are you taking any pain killers/narcotics/opioids? Please list all

Aspirin Non-Steroidal Anti-Inflammatory Drug (NSAID) Blood Thinner (Coumadin?, Plavix?, Lovenox?) Narcotics ie- Percocet?/Vicodin?/Oxycodone?/Tramadol?

Drug

Dosage

Frequency

Yes No Yes No Yes No Yes No

Reason Prescribed

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SYSTEM REVIEW

Check all symptoms which you have, or have had. Write in any additional problems.

HEAD, EYE, EAR, NOSE & THROAT:

STUFFY NOSE

RUNNY NOSE

SINUS TROUBLE

EARACHE

BLURRY VISION

DOUBLE VISION

LOSS OF NIGHT VISION

BUZZING IN EARS

DISCHARGE FROM EAR

LOSS OF HEARING

VERTIGO

LOSS OF BALANCE

LUMP IN THROAT

TROUBLE SWALLOWING

PAIN WITH SWALLOWING

HAY FEVER HEADACHE HALOS AROUND LIGHTS RINGING IN EARS DIZZINESS SORE THROAT HOARSENESS

RESPIRATORY:

BRONCHITIS

WHEEZING

USE TWO PILLOWS

BLOOD IN SPUTUM

COUGH

EMPHYSEMA

WAKE UP AT NIGHT COUGHING

OR CHOKING

ASTHMA OUT OF BREATH WITH EXERTION SHORTNESS OF BREATH AT NIGHT WAKE UP AT NIGHT SHORT

OF BREATH

CARDIOVASCULAR: PALPITATIONS PAINS IN CHEST HEART ATTACK COLD FEET IRREGULAR HEARTBEAT BLUE TOES

POUNDING OF HEART PAINS IN NECK HEART MURMUR LOSS OF PULSES HIGH BLOOD PRESSURE BLUE FINGER

SKIPPING OF HEARTBEAT PAINS IN ARMS SQUEEZING OF CHEST ABNORMAL ELECTROCARDIOGRAM PAIN IN LEGS

GASTROINTESTINAL: HEARTBURN GASSINESS CONSTIPATION BURNING IN THROAT BURNING IN STOMACH FISSURES

NAUSEA ACID STOMACH HEMORRHOIDS PAINS IN STOMACH BLOOD IN STOOLS CRAMPS

VOMITING DIARRHEA BELCHING FLUID IN THROAT FOOD STICKING IN CHEST PAIN WITH BOWEL MOVEMENT IRRITABLE COLON COLITIS

GENITOURINARY:

PAIN WITH URINATION

TROUBLE STARTING URINE TROUBLE STOPPING URINE

SMALL URINE STREAM

BLOOD IN URINE

KIDNEY FAILURE

NEPHRITIS

FREQUENT URINATION

URINARY TRACT INFECTIONS

KIDNEY STONES

GETTING UP AT NIGHT TO URINATE

LEAKAGE OF URINE WITH COUGH OR SNEEZE

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MEN: DISCHARGE FROM PENIS

LOSS OF ERECTION

PAINFUL ERECTION

OB/GYN: VAGINAL DISCHARGE PAIN WITH INTERCOURSE

VAGINAL BLEEDING IRREGULAR PERIODS

ENDOCRINE (GLANDULAR):

LOW THYROID

HYPERTHYROID

GRAVE'S DISEASE

THYROID NODULES

DIABETES

ADRENAL GLAND TUMOR

FREQUENT HEAVY SWEATING

GOITER FREQUENT FLUSHING

MUSCULOSKELETAL: PAIN IN JOINTS FLUID IN JOINTS SPRAINS HIP PAIN FOOT PAIN HERNIATED DISK

SWELLING OF JOINTS

WARM JOINTS

ARTHRITIS

BROKEN BONES

LOW BACK PAIN

SCIATICA

KNEE PAIN

ANKLE PAIN

FLATFEET

SLIPPED DISK

REDNESS OF SKIN OVER JOINTS

NEUROLOGICAL: DIZZINESS FALLING AT NIGHT SHAKINESS TWITCHING OF MUSCLES FAINTING LOSS OF CONSCIOUSNESS

VERTIGO

FALLING TO THE SIDE

NUMBNESS

TINGLING

PINS & NEEDLES FEELINGS WEAKNESS OF ANY MUSCLES

WEAKNESS OF GRIP

TREMOR

CONVULSIONS

FITS

PSYCHOLOGICAL: NERVOUSNESS PSYCHOLOGICAL COUNSELING SUICIDE ATTEMPTS HOSPITALIZATIONS FOR EMOTIONAL PROBLEM

DEPRESSION THOUGHTS OF SUICIDE PSYCHIATRIC TREATMENT ANXIETY

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FAMILY HISTORY

Please indicate if there is a family history of:

Obesity Diabetes High blood pressure Heart disease High blood cholesterol

Lung disease, asthma or emphysema Kidney disease Bleeding tendency or blood disorder Breast cancer Colon cancer

SOCIAL HISTORY

Marital Status: S: ___ M: ____ D: ____ W: ____

Religion:

Level of Education:

Persons Living in the Home:

Smoking History: Never Former Smoker Year Quit: _______

CURRENTLY Smoking OR Vaping :

Yes No

Number of packs per day:

Number of years:

Are you willing to quit? Yes No

Recreational Drug Use: Yes No Describe:

Alcohol Intake

Yes No

Frequency of alcoholic beverages: None Light Moderate

Heavy

WEIGHT HISTORY

Please estimate as closely as possible for all that applies.

Life Event

Age

Birth Weight

Start of High School

High School Graduation

Marriage

Lowest Weight in Past 5 Years

Highest Weight in Past 5 Years

Weight

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Weight Loss Attempts

Method Weight Watchers

Yes # Months

Jenny Craig

Nutri-Systems

Opti/Medi Fast

Phen Fen/Redux

Phentarmine

Meridia

Xenical / Orlistat

Ephedra

Metabolife

Nutritionist

Slim Fast

Atkins

South Beach

Overeaters Anonymous

Weight Loss Camp

Medically Supervised Wt Loss

Doctor Prescribed Diet

Hypnosis

Acupuncture

List any other wt loss attempt(s)

Year

# of Pounds Lost

Wt Regained

Previous weight loss surgery Yes No

Date of Surgery: ______________

Name of Surgeon: _______________________________

Name of operation:

Wt at Operation:

Max Amt Wt Lost: _________

Please list any other information you feel is important for your Dietitian:

The above is true and correct to the best of my belief Print Patient Name: Surgeon: _____________________________

Patient Signature: _____________________ Date: _______________________________ Date Reviewed with Patient: _____________ Surgeon Signature: _____________________

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Dear our "Future Weight Loss Warrior,"

The Registered Dietitians will be working with you throughout your journey to success. We call it a personal journey because we will be working closely together in achieving your every goal. In order to better assist you with your individual needs, we ask that you carefully fill out the following paper work in DETAIL. We want to know who you are, and what your habits are like, so together we can create a plan that works best for you. This is not a diet!! This is a lifestyle. Only with the proper information can we provide a plan that will get you to where you want to be, both physically and emotionally.

If any pages of these packets are skipped, it will delay comprehensive service. Looking forward to meeting you!

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