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 monthly informational seminars and/or webinars. 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 at or call (410) 601-4486.
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 either Sinai Hospital or Chartwell Professional Center. Adherence to the program greatly increases your success following bariatric surgery. Both programs 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 Hospital. 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 or webinars.
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, these tests will be ordered on an individual basis after you have met with one of the surgeons. If you have any questions about LifeBridge Health Bariatric Surgery Program and our locations, 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: |Synalogos-DC |
|Aggrenox |Ecotrin (Adult Low Strength, Maximum Strength) |Trilisate |
|Alka-Seltzer (Effervescent pain reliever and antacid,|Ecprin |Vanquish |
|lemon-lime effervescent pain reliever and antacid, |Endodan |Zorprin |
|extra strength effervescent pain reliever and |Entercote | |
|antacid, Morning relief) |Equagesic |NSAIDS products: |
|Anacin (maximum strength) |Excedrin (extra-strength, migraine) |Diclofenac (Flector, fcataflam, Voltaren, Arthrotec,|
|Ascriptin (enteric regular strength, regular |Fiorinal |Cataflam, Cambia) |
|strength, arthritis pain) |Fortabs |Diflunisal (Dolobid) |
|AsperDrink |Gelprin |Etodolac (Lodine) |
|Aspergum |Genacote |Fenoprofen (Nalfon) |
|Aspirin/butalbital/caffeine |Goody’s (body pain formula powder, extra strength |Flurbiprofen (Ansaid) |
|Aspirin with buffers |headache powders, extra strength pain relief tablets)|Ibuprofen (Advil, Motrin, Genpril, Haltran, Menadol,|
|Aspirtab |Halfprin |Midol, Vicoprofen, Dristan) |
|Aspir-Trin |Orphenadrine P-A-C analgesic |Indomethacin (Indocin) |
|Bayer (Children’s Chewable, Adult Low Strength, |Magnesium salicylate (Doan’s, Backprin, Keygesic, |Ketoprofen (Oruvail, Orudis) |
|Genuine Bayer, regular strength caplets, women’s |Momentum, Agesic, Mobidin, Novasal, Pamprin) |Ketorolac (Toradol, Acular, Acuvail, Sprix) |
|aspirin plus calcium caplets, extra strength back and|Magnaprin (Improved, arthritis strength) |Meclofenamate |
|body pain) |Micrainin |Mefenamic (Ponstel) |
|BC Powder (arthritis strength) |Miniprin |Meloxicam (Mobic) |
|Bismuth Subsalicylate (Pepto |Norgesic (Forte) |Nabumetone (Relafen) |
|Bismol, Kaopectate, Bismatrol, Kola-Pectin, Diotame, |Norwich Aspirin |Naproxen (Naprosyn, Prevacie Napra PAC, Aleve, |
|Kapectolin, Bismate, Bismakote, Bismuth, Stomach |Pamprin |Naprelan, Anaprox) |
|Relief, Kao-Tin, Kensorb, Kao-Paverin, Peptic Relief,|Percodan |Oxaprozin (Daypro) |
|Sootheze) |Robaxisal |Piroxicam (Feldene) |
|Bufferin (arthritis strength, extra strength) |Soma |Salsalate (Disalcid, Amigesic, Salflex, Persistin, |
|Carisoprodol Compound (with codeine) |Stanback Powder |Mono-gesic, Marthritic, Arthra-G, Argesic-SA) |
|Citrated/Aspirin/caffeine |St.Joseph (Adult Low Strength chewable, Adult Low |Sulindac (Clinoril) |
|Cope |Strength enteric coated tablets) |Tolmetin (Tolectin) |
|Damason-P |Store brands (Good Neighbor Pharmacy, Good Sense, | |
|Easprin |Leader, Medi-First, Quality Choice, Top Care, Rite |Cox-2 Inhibitors |
| |Aid) |Celecoxib (Celebrex) |
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****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 - 13 and the Nutritional Assessment on pages 15 – 18.
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/webinars (see enclosed flyer for dates).
Please include copy of driver’s license and insurance card (front & back) with application
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 43775) | |
|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 the specialist? |Yes No |
|Is there a co-pay to see the Specialist? |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 having: | |I am interested in seeing the doctor & dietitian: |
|-CHOOSE A PROCEDURE - | |-CHOOSE A LOCATION - |
| |Gastric Bypass | | |NorthWest Hospital Center |
| |Sleeve Gastrectomy | | |Sinai Hospital |
| |Laparoscopic Band | | |Dorsey Hall- Ellicott City, MD |
|First Name: | |Middle Initial: | |
|Last Name: | |Gender: |M F |
|Social Security No.: | | |
|Birth Date: | |Current Age: | |
|Weight: |
Contact Information:
|Home Address: | |Apt/Unit #: | |
|City: | |Stat|
| | |e: |
| | |May we contact you at this number? | |
|Home Number: | | Yes | No | Preferred |
|Employer: | |Occupation: | |
|Employers Address: | | |
| | | |
|Length of time @ current employment: ________ Years ________ Months | |
NAME: _________________________________
Emergency Contact Information:
|Name: | |Relationship: | | |
|Home Address: | |City, State, Zip: | | |
|Home Number: | |Cell Number: | | |
|Work Number: | | | | |
Pharmacy Information:
|Pharmacy Name: ________________________________________________________________ |
|Address: ______________________________ |City, State, Zip: ________________________ |
|Phone Number: ________________________ |Fax Number: ___________________________ |
| |Primary Care Physician | |Other Physician | |
|Name: | | | | |
|Specialty: | | | | |
|Address: | | | | |
|Address 2: | | | | |
|City: | | | | |
|State: | | | | |
|Zip: | | | | |
|Phone Number: | | | | |
|Fax Number: | | | | |
Physician Information:
NAME: ________________________________
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: | | | |
I heard about Sinai Bariatric through:
|( Family/Friend |( Magazine |( TV |
|( Insurance |( Newspaper | |
|( Internet |( Primary Care Physician |( Other: |
NAME: _________________________________
| |
|The doctor will complete this section. |
|CC: Morbid obesity |
|HP: This is a _______ year old male/ female G __ P __ A__ morbid obese patient interested in bariatric surgery. His/Her current weight is _____ lbs. |
|and a height of ____ resulting in a BMI of _____. His/Her ideal weight should be _____ lbs. for a BMI of 25. His/Her excess weight has been |
|calculated to be _____ lbs. He/She has been unable to control or reduce their weight by medical management. |
Medical History (α all that apply):
| Anxiety | Fibromyalgia | Reflux Disease (Heartburn or |
| | |severe indigestion) |
| Arthritis | Heart Attack | Seizures |
| Asthma | High blood pressure | Sleep Apnea |
| |(Hypertension) |Diagnosed Observed |
| Bronchitis | Hypercholesterolemia | Snore |
| |(High cholesterol) | |
| Cancer | Hypertriglyceridemia | Stress Incontinence |
| |(High triglycerides) | |
| Cardiac Surgery | Hyperthyroidism | Stroke |
| Chest Pains | Hypothyroidism | Varicose Veins |
| CHF | Leg Ulcers | Other : |
| Depression | Lower back pain | |
| Diabetes Type I | Migraines/Headache | |
|(Insulin dependent) | | |
| Diabetes Type II | Peripheral Edema | |
|(Non-insulin dependent) |(Swelling of the legs) | |
| DVT (Leg Blood Clots) | Pneumonia | |
NAME: _________________________________
|Surgery |Date |Comment |
| C section | |Number: |
| Gall Bladder | | Open | Laparoscopic | |
| Tubal Ligation | | |
| Other (list surgeries and year) : |
| |
| |
Surgical History (α all that apply): ( Check if no surgical history
Hospital Admissions: ( Check never been admitted to the hospital
|Hospital |Date |Reason |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
NAME: ________________________________
Health History (α all that apply):
|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 or Attack | High Blood Pressure |
| | | Leg Swelling |Other (please list): |
|RESPIRATORY | Cough | Asthma/Bronchitis | Shortness of Breath |
|N/A | | | |
| | Wheezing | Sleep Apnea | Other (please list): |
| | |Diagnosed Observed | |
|GASTROINTESTINAL |History of Ulcers |Abdominal pain |Changes in bowel habits |
|N/A | | | |
| |Difficulty w/ swallowing |Vomiting |History of blood transfusion |
| |Nausea |Bloody Stools |History of polyps |
| |Heartburn/Reflux |Jaundice |Other (please list) |
|URINARY |Difficulty urinating |Stress incontinence |Frequent UTI/Kidney Infections |
|N/A | | | |
| |Urinating at night |Kidney stones | Other (please List) |
|NEUROLOGIC |Numbness or tingling |Weakness |Other (please list) |
|N/A | | | |
| |Seizures |Previous Stroke | |
|ORTHOPEDICS |Back pain | Arthritis | Difficulty walking |
|N/A | | | |
| | History of fractures |Body Aches |Other (please list) |
|PSYCHIATRIC |Panic attacks |Sleeping difficulties |Bipolar disorder |
|N/A | | | |
| |Chronic depression |Attempted suicide |Other (please list) |
|ENDOCRINE |Thyroid Problems |Hair Loss | Other (please list) |
|N/A | | | |
| |Menstrual Problem |Diabetes | |
| | |Insulin Non-Insulin | |
|HEALTH SCREENING |Last Mammogram |Last Pap Smear or Prostate exam |EGD (date)________ |
|N/A | | |Colonoscopy (date)________ |
|HEMATOLOGY |Anemia |Enlarged lymph nodes |Other (please list) |
|N/A | | | |
| |Bleeding |History of cancer | |
|IMMUUNOLOGIC |HIV | Hepatitis B or C | Other (please list) |
|N/A | | | |
| | Other (please list) | | |
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 |Purpose |
|Religion: |Do you use tobacco products? |Yes Never Smoked |
|Catholic |If yes, what kind: |Former Smoker |
|Jehovah Witness |Cigarettes |If yes, how much: |
|Jewish |Cigars |1/2 pack or less per day |
|Prostestant |Chewing tobacco |Between 1 – 1.5 packs per day |
|Other (List): __________________ | |Between 1.5 – 2 packs per day |
| | |2 packs or more per day |
|Do you drink alcohol? Yes |No |Have you ever used illegal drugs? Yes No |If you still use drugs, how |
|If yes, how much: |If yes, how often: |If yes, what kind: |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 have 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: |
| |Weight |Health Problems |
|Mother | |Diabetes |Sleep Apnea |
| | |Heart Disease |Joint Disease |
| | |High BP |Stroke |
| | |High Cholesterol |COPD |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
|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 amounts you take:_____________________________________________________
NAME: _________________________________
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 substitutes ( Other: ___________________________________________________
7. Do you use sugar substitutes? ( Yes ( No If yes, which one? ________________
5. What do you do for a living and how many hours do you worked per week? ___________
9. Do you travel with 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 choices? ( Yes ( No If yes, please elaborate ____________________________________________________
14. Are the meals cooked in the home low fat? ( 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 ( Margarine ( 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
NAME: _________________________________
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 gained or lost? Gained _____ pounds Lost _____ pounds
30. What do you think is a realistic weight for you? _______________________________
|List the diets/programs have you have tried within |Year |Length in Months |Number of Pounds Lost |
|the last 5 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. ____________________________________________________________
NAME: _________________________________
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, which ones and how often? ___________________________________________
_______________________________________________________________________
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? ( Yes ( No Such as binge eating and then vomiting or not eating or eating very little for long periods of time. If so, 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 due to:
( Reading problems ( Deafness
( Poor eyesight ( Other: _________________________
Charlotte Dunlap RD, LDN
410-701-4881 (Office) 410-601-9014(Fax)
chadunla@
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