New Bariatric Surgery Patient Intake Questionnaire



BMI of Texas

9910 Huebner Rd, Suite #250 San Antonio TX 78240

Phone (210)615-8500 Fax (210)615-8501

New Bariatric Surgery Patient Intake Questionnaire

In order to minimize your wait time and maximize your experience at BMI of Texas, please take a moment to complete this questionnaire. We realize this is a lengthy form but assure you it is all important information and will be kept confidential.

Please Print

First Name: ________________________Last Name: _______________________DOB:_________________

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How did you hear about us? _________________________________________________________________

When was your last Band Adjustment? ________________________________________________________

When was your last follow up with your surgeon? _______________________________________________

Who did your weight loss surgery? ___________________________________________________________

Adjustable Gastric Band

Are you currently experiencing any of these symptoms?

Nausea ( yes ( no

Vomiting ( yes ( no

Difficulty Swallowing ( yes ( no

Heartburn or Reflux ( yes ( no

Regurgitation ( yes ( no

Night Cough ( yes ( no

Poor Eating Behavior ( yes ( no

Do you drink Alcohol? ( yes ( no

Do you smoke? ( yes ( no

Do you exercise? ( yes ( no

If yes, how many times a week? _______

Do you attend support group meetings?

( yes ( no

Quality of Life (circle)

Very Satisfied Somewhat dissatisfied

Satisfied Dissatisfied

Somewhat satisfied Very dissatisfied

Neutral

Diet History

Tolerating meats/solid foods? ( yes ( no

Tolerating Hunger? ( yes ( no

Eating sweets? ( yes ( no

Tolerate drinking sodas? ( yes ( no

Portion Size (compared to pre-surgery)

(25% (50% (75% (100%

How many hours after a meal are you hungry?

(1-2 (3-4 (5-6 (never

Do you eat soft mush foods because you are afraid of solid foods?

(Yes (no

Would you do weight loss surgery again knowing what you know now? (Yes (No

Have you ever fainted from a needle stick or have a fear of needles? (Yes (No

Are you pregnant or think you may be? ( yes ( no

If no, when was your last LMP? ____________

Medications: Please list below any and all medications/vitamins you are currently taking.

Example: Lipitor 10mg one tablet daily at bedtime

1.____________________________________________________

2.____________________________________________________

3.____________________________________________________

4.____________________________________________________

5.____________________________________________________

6.____________________________________________________

7.____________________________________________________

8.____________________________________________________

9.____________________________________________________

10. ___________________________________________________

❑ Not currently taking any medications

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Allergies: Do you have allergies to any of the following:

❑ Medications, if so, please list medication and reaction: __________________

_______________________________________________________________

_______________________________________________________________

❑ Latex

❑ Iodine, when: ____________________________________________________

❑ IV Contrast, when: ________________________________________________

❑ Adhesives, type: _________________________________________________

❑ No Known Allergies

Medical History

Please carefully review the list of medical conditions/problems listed below and check any that apply to you:

❑ Angina

❑ Allergic Rhinitis

❑ Anxiety

❑ Asthma

❑ Breast Cancer

❑ Heart Disease w/bypass surgery

❑ Heart Disease without bypass surgery

❑ Cardiomyopathy

❑ Carpal Tunnel Syndrome

❑ Chest pain with exertion/exercise

❑ Gallstones

❑ Chronic Back Pain

❑ Congestive Heart Failure

❑ Stroke

❑ DVT (Blood Clot)

❑ Degenerative Disk Disease

❑ Depression

❑ Type I Diabetes/Insulin Dep (controlled)

❑ Type I Diabetes/Insulin Dep (Uncontrolled)

❑ Type II Diabetes/Adult Onset (Controlled)

❑ Type II Diabetes/Adult Onset (Uncontrolled)

❑ Abnormal Uterine Bleeding

❑ Dysmenorrhea (Excessively painful menses)

❑ Shortness of breath with exertion/exercise

❑ Abnormally elevated liver function tests

❑ Fatigue

❑ Fatty liver (due to alcohol)

❑ Fatty liver (NOT related to alcohol)

❑ Fibrocystic breast disease

❑ Fibromyalgia

❑ Acid Reflux Disease/GERD

❑ Gestational Diabetes (diab w/pregnancy)

( Glucose Intolerance

❑ Gout

❑ Heartburn/Indigestion

❑ Hemorrhoids

❑ High Cholesterol

❑ Hypertension (high blood pressure)

❑ High triglycerides

❑ Hypothyroidism (Underactive thyroid)

❑ Infertility

❑ Insomnia

❑ Intermittent Claudication

❑ Intertriginous Dermatitis (irritation of the skin folds)

❑ Irritable Bowel Syndrome

❑ Joint Pain

❑ Menstrual Irregularity

❑ Migraine Headaches

❑ Myocardial Infarction (Heart Attack)

❑ Swelling of the legs (edema)

❑ Peripheral Vascular Disease

❑ Stomach Ulcers

❑ Polycystic Ovarian Syndrome (PCOS)

❑ Pseudotumor Cerebrii

❑ Pulmonary Embolus (blood clot to lungs)

❑ Seasonal Allergies

❑ Sleep Apnea

❑ Sleeping Disorder

❑ Stress Urinary Incontinence (leaking urine with

cough/straining)

❑ Thrombophlebitis

❑ Urinary Urge Incontinence (can’t hold urine)

❑ Varicose Veins

❑ Venous Insufficiency

Surgical History:

Please list non-bariatric surgeries (surgeries not related to weight loss) you have had or indicate if you have not had any. ( No prior non-bariatric surgeries

Example: Open Hysterectomy w/ ovaries removed, 1/25/99, no complications

Procedure/Surgery:

specify laparoscopic/Open Date: Complications:

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

Please list previous bariatric (weight loss) surgeries:

( No prior bariatric surgeries

Procedure/Surgery:

(laparoscopic/Open) Date: Original Weight: Lowest Weight Complications:

| | | | | |

| | | | | |

| | | | | |

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Disability:

Are you currently considered to be disabled by the U.S. Social Security Administration?

( Yes ( No

If yes, for what reason are you disabled? Year of disability: ________________

❑ Motor vehicle accident

❑ Disability due to recent disabling illness

❑ Work related disability

❑ Disability due to chronic medical condition: (describe)__________________________

Do you require assistive device? ( Yes ( No

If yes, indicate which type? ( Cane ( Crutches ( Walker ( Braces

Do you utilize a wheelchair or motorized scooter? ( Yes ( No

If yes, how long have you required this assistance? __________________________________

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Family History: (Please include only parents, grandparents, and siblings)

Illness/Medical Condition Family Member

_________________________________ __________________________________

_________________________________ __________________________________

_________________________________ __________________________________

_________________________________ __________________________________

_________________________________ __________________________________

_________________________________ __________________________________

_________________________________ __________________________________

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Social History:

Do you currently smoke? ( No ( Rarely ( Occasionally ( Frequently

For past smokers, what year did you quit? ____________

How many years ago did you quit smoking? ___________

Do you drink alcohol? ( No ( Rarely ( Occasionally ( Frequently

If yes, how many times/week? __________________________

Do you currently use illicit/street drugs? ( No ( Rarely ( Occasionally ( Frequently

If yes, what type did/do you use and how often? _________________________________________

*Note to patient: We apologize for the length of this form but we feel that all of this information is very important to enable our office and staff to provide you with excellent care.

Review of Systems

General: Please check any/all that apply to you:

Functional Status: Check any/all that apply to you:

Pseudotumor Cerebri: Check any/all that apply to you:

Abdominal Hernia: Check any/all that apply to you:

Stress Urinary Incontinence: Check any/all that apply to you:

General (Continued):

Abdominal Skin / Pannus

\

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Skin

Please check any/all that apply to you:

❑ Rash under folds /breasts ( Hair/Nail Changes

❑ Keloids/large scars ( Rosacea

❑ Poor Wound Healing

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Blood:

Please check any/all that apply to you:

( Anemia (Iron deficiency) ( Bleeding Disorder

❑ Anemia (B12 deficiency) ( Lymphoma

❑ HIV / AIDS ( Blood Transfusion

❑ Low Platelets ( Use of Blood Thinners

❑ Swollen Lymph Nodes ( Easy Bruisability

❑ Superficial clot in leg

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Endocrine / Metabolic

Gout: Check any/all that apply to you:

Diabetes: Check any/all that apply to you

Endocrine/Metabolic Continued:

Dyslipidemia: (abnormal cholesterol/triglycerides)

Check any/all that apply to you:

Please check any/all that apply to you:

❑ Excessive urination ( Abnormal facial hair growth

❑ Excessive thirst ( Hypothyroid (low thyroid)

❑ Low blood sugar ( Hyperthyroid (overactive)

❑ Endocrine gland tumor ( Parathyroid Problems

❑ Elevated Calcium level ( Goiter

Other: _________________________________________________

_________________________________________________

_________________________________________________

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Respiratory

Sleep Apnea-please check any/all that apply to you:

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Pulmonary Hypertension, check any/all that apply to you:

Respiratory (continued):

Asthma, check any/all that apply to you:

Obesity Hypoventilation Syndrome: Check any/all that apply to you:

Please check any/all that apply to you:

( Chronic cough

❑ Shortness of Breath at rest

❑ Emphysema/COPD

❑ Bronchitis

❑ Pneumonia

❑ Suspicious of Sleep Apnea but not ever diagnosed

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Psychosocial

Psychosocial Impairment: Check any/all that apply to you:

Confirmed Mental Health Disorder: Check any/all that apply to you:

Psychosocial (continued):

Depression: Check any/all that apply to you:

Check any/all that apply to you:

Alcohol Use: Tobacco Use: Substance Abuse:

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Neurologic

Please check any/all that apply to you:

❑ Migraine ( Dizziness

❑ Balance disturbance ( Stroke

❑ Seizure or Convulsions ( Multiple sclerosis

❑ Weakness ( Restless Leg

❑ Recurrent headaches ( Knocked unconscious

❑ Numbness and Tingling

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Musculoskeletal Disease

Back Pain: Check any/all that apply to you:

Musculoskeletal Disease (continued):

Fibromyalgia: Check any/all that apply to you:

Musculoskeletal Disease: Check any/all that apply to you:

Please check any/all that apply to you:

❑ Neck Pain ( Lupus

❑ Shoulder Pain ( Scleroderma

❑ Wrist Pain ( Autoimmune Disease

❑ Hip Pain ( Muscle Pain

❑ Knee Pain ( Sciatica

❑ Ankle Pain ( Plantar fasciitis

❑ Foot Pain ( Carpal Tunnel

❑ Heel Pain ( Rheumatoid arthritis

❑ Ball of foot / Toe Pain ( Broken Bones

Other: ________________________________________________

________________________________________________

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Gynecologic – Breast

Please check any/all that apply to you:

❑ Breast Lumps ( Problems conceiving

❑ Breast Pain ( Post Menopausal

❑ Fibrocystic disease ( Dysmenorrhea

❑ Nipple discharge ( Uterine / ovarian cancer

( Breast Cancer ( Breast surgery

Polycystic Ovarian Syndrome: Check any/all that apply to you:

Gynecologic –General (continued):

Menstrual Irregularities: Check any/all that apply to you:

Pregnancies: Check any/all that apply to you:

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Bladder: Check any/all that apply to you:

( Kidney Stones ( Kidney Failure / Renal Insuff

❑ Blood in Urine ( Leaking Urine when Sneezing

❑ Prostate Problems ( Previous PSA test (males only)

❑ Burning on urination ( Trouble Starting

( Urinary Urgency

Gastrointestinal

Please check any/all that apply to you:

❑ Abdominal Pain ( Colitis

❑ Heartburn ( Crohn’s Disease

❑ Stomach Ulcers ( Hemorrhoids

❑ Hiatel Hernia ( Rectal Bleeding

❑ Incisional Hernia ( Black tarry stools

❑ Diarrhea ( Colon Polyps

❑ Blood in stool ( Pancreatic Disease

❑ Change in Bowel Habits ( Barrett’s Esophagus

❑ Constipation ( Difficulty Swallowing

❑ Irritable Bowel ( Nausea /Vomiting

Other: _____________________________________________________

_____________________________________________________

_____________________________________________________

Gastrointestinal (continued):

GERD (Gastroesophageal Reflux Disease): Check any/all that apply to you:

Gallstones: Check any/all that apply to you:

Liver Disease: Check any/all that apply to you:

Cardiac

Hypertension: Check any/all that apply to you:

Angina: Check any/all that apply to you:

Cardiac (continued):

Congestive Heart Failure: Check any/all that apply to you:

Peripheral Vascular Disease: Check any/all that apply to you:

Deep Venous Thrombosis: Check any/all that apply to you:

Ischemic Heart Disease: Check any/all that apply to you:

Lower Extremity Edema: Check any/all that apply to you:

Cardiac (continued):

Please check any/all that apply to you:

❑ Pacemaker ( Heart Murmur / Atrial Fibrillation

❑ Rapid Heart Rate ( Irregular / Skipped heart beats

❑ Varicose Veins ( Rheumatic fever / Valve Damage / MVP

Other: ______________________________________________________

______________________________________________________

______________________________________________________

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Constitutional: Please check any/all that apply to you:

( Fevers ( Anemia ( Weight Gain

( Chills ( Hair Loss ( Insomnia

( Night Sweats ( Fatigue ( Appetite Change

Other: _______________________________________________________

_______________________________________________________

Head and Neck: Please check any/all that apply to you:

( Wears Contacts / Glasses ( Sinus Drainage

( Blurred / Double Vision ( Dentures (partial/full)

( Glaucoma ( Ear Infections

( Hearing Problems ( Nose Bleeds

( Chronic Allergies ( Hoarseness

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❑ No history of sleep apnea

❑ Symptoms but sleep study/test negative

❑ Positive sleep study/test

❑ Require appliance/CPAP at night

❑ Have hypoxia (low oxygen) or dependent on oxygen

❑ Have complications related to sleep apnea

❑ No history of Pulmonary Hypertension

❑ Symptoms only (tiredness, shortness of breath, dizziness)

❑ Confirmed diagnosis

❑ Well controlled on medications

❑ Require oxygen or stronger meds

❑ Pt needs/requires or has had lung transplant

❑ No history of Asthma

❑ Occasional Mild Symptoms, not on any meds

❑ Symptoms controlled on oral meds or inhalers

❑ Well controlled with daily medications

❑ Poorly controlled, requiring steroids or anticholinergics

❑ Hospitalization in the last 2 years/history of intubation

❑ No history of OHS

❑ Low oxygen on room air

❑ Severely low oxygen

❑ Pulmonary Hypertension

❑ Right Heart Failure

❑ Right heart failure/Left Ventricular Dysfunction

❑ No impairment

❑ Able to walk 200 ft with assist device (cane/crutch)

❑ Cannot walk 200 ft with assist device (cane/crutch)

❑ Requires wheelchair

❑ Bedridden

❑ No Symptoms

❑ Headaches with dizziness, nausea, and/or pain behind eyes

❑ Headaches with visual symptoms, and/or controlled with diuretics

❑ MPI confirmed diagnosis of PTC

❑ Well controlled with stronger medications

❑ Requires narcotics, surgical intervention done or recommended

❑ No hernia

❑ Asymptomatic hernia, no prior operation

❑ Successful repair

❑ Recurrent hernia or size >15cm

❑ Chronic evisceration through large hernia or multiple failed repairs

❑ No Symptoms

❑ Minimal and intermittent

❑ Frequent but not severe

❑ Daily occurrence, requires sanitary pad

❑ Disabling

❑ Failed surgery

❑ No Symptoms

❑ Intertriginous irritation

❑ Pannus is large enough to interfere with ambulation

❑ Recurrent cellulitis or ulceration

❑ Surgical treatment

❑ No gout present

❑ Hyperuricemia present but no symptoms

❑ Hyperuricemia present, on medications

❑ Arthropathy present

❑ Destructive joints present

❑ Disabled, no walking

❑ No Diabetes

❑ Elevated fasting glucose

❑ Oral meds only

❑ Insulin only

❑ Insulin and oral meds

❑ Complications present

❑ No Dyslipidemia

❑ No treatment required

❑ Lifestyle change

❑ Single medication

❑ Multiple medication

❑ Poorly controlled

❑ No impairment

❑ Mild impairment, able to perform primary tasks

❑ Moderate impairment, able to perform most primary tasks

❑ Moderate impairment, unable to perform most primary tasks

❑ Severe impairment, unable to function

❑ None

❑ Bipolar

❑ Anxiety/Panic Disorder

❑ Personality Disorder

❑ Psychosis

❑ No Symptoms

❑ Episodic, no treatment required

❑ Moderate with some impairment, may require treatment

❑ Moderate with significant impairment, treatment indicated

❑ Severe, intensive treatment indicated

❑ Severe, hospitalization required

( No tobacco

( Rarely

( Occasionally

( Frequently

( No

( Rarely

( Occasionally

( Frequently

( No alcohol

( Rarely

( Occasionally

( Frequently

❑ No Back Pain

❑ Intermittent symptoms

❑ Non narcotic treatment

❑ Degenerative changes, narcotic treatment

❑ Surgical treatment done or recommended

❑ Failed surgical treatment

❑ No fibromyalgia

❑ Treatment with exercise

❑ Treatment with non narcotic medications

❑ Treatment with narcotics

❑ Surgical Treatment done or recommended

❑ Disabled, surgery failed

❑ No musculoskeletal disease

❑ Pain with community ambulation

❑ Non narcotic analgesia

❑ Pain with household ambulation

❑ Surgical intervention required

❑ Joint replacement done or recommended

❑ No POS

❑ Polycystic Ovarian Synd - Symptoms, no treatment

❑ Polycystic Ovarian Synd - OCP’s or anti-androgen treatment

❑ Polycystic Ovarian Synd – Metformin or TZD

❑ Polycystic Ovarian Synd – combination therapy

❑ Polycystic Ovarian Synd - infertility

❑ No irregularities

❑ Irregular periods

❑ Menorrhagia (heavy bleeding with periods)

❑ Amenorrhea (lack of periods/bleeding)

❑ Prior hysterectomy

Are you Pregnant: ( Yes ( No

Are you planning more children? ( Yes ( No

How many Pregnancies? ________

How many children? ________

How many miscarriages / Abortions? ________

❑ No GERD

❑ Variable symptoms

❑ Require only intermittent medications

❑ H2 blockers (pepcid, zantac) or low dose PPI (Prevacid, Prilosec, Nexium, etc)

❑ High dose PPI

❑ Criteria for or history of anti-reflux surgery

❑ No Gallstones

❑ Asymptomatic (stones present)

❑ Intermittent symptoms

❑ Severe symptoms, previous cholecystectomy

❑ Immediate GB surgery prior to weight loss surgery

❑ Previous cholecystectomy with unresolved complications

❑ No Liver Disease

❑ Mild hepatomegaly, normal LFT’s, cat. 1 fatty liver

❑ Mod. hepatomegaly, altered LFT’s, cat. 2 fatty liver

❑ Marked hepatomegaly, cat. 3 fatty liver, mild fibrosis

❑ NASH, cirrhosis, hepatic dysfunction

❑ Failure, need for or previous transplant

❑ No Hypertension

❑ Borderline HTN

❑ Positive diagnosis

❑ Controlled with single medication

❑ Multiple Medications

❑ Poorly Controlled

❑ No Angina

❑ Angina with extreme exertion

❑ Angina with moderate exertion

❑ Angina with minimal exertion

❑ Unstable Angina

❑ Previous MI by history or work-up

❑ No CHF

❑ Class I – exertion only

❑ Class II – ordinary activity

❑ Class III – minimal activity

❑ Class IV – at rest

❑ No PVD

❑ Asymptomatic with bruit

❑ Claudication, anti-ischemic meds

❑ Transient ischemic attack, rest pain

❑ Previous procedure for PVD

❑ Stroke, loss of tissue

❑ No Previous DVT

❑ Resolved with medications

❑ History of recurrent DVT’s

❑ Previous PE

❑ History of recurrent PE’s

❑ Has Vena Cava Filter

❑ No IHD

❑ Abnormal EKG

❑ History of MI/anti-ischemic meds

❑ Previous CABG/catheterization

❑ Active ischemia

❑ No edema

❑ No treatment

❑ Treatment

❑ Stasis ulcers present

❑ Disability, hospitalization

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