Bariatric new patient

Bariatric new patient
Patient Information
Name *

First Name Middle Name Last Name
Preferred Name
Prefix
Suffix
D.O.B *

Month Day Year
SSN *
Sex *

Male Female
Race *
Marital Status *
Ethnicity *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
On this date, I authorize Great Lakes Surgical Associates to contact me or leave a message at the following contact methods:

Home Work Cell Email
Preferred Method of Contact *

Text Message Email Home Phone Cell Phone
Employer
If patient is a minor: Parent/Legal Guardian's Name: *
Relationship *
D.O.B *

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Care Physician's Name *
Enter N/A if you do not have a PCP
Phone
Please enter a valid phone number.
City, State
Referring Physician's Name
Phone
Please enter a valid phone number.
City, State
Emergency Contact & Relationship *
Phone *
Please enter a valid phone number.
Primary Insurance: *
If you do not have insurance, please specify "none"
Policy # *
If you do not have insurance, please specify "none"
Group #
Subscriber: Name, Relationship, D.O.B:
Secondary Insurance:
Policy #
Group #
Subscriber: Name, Relationship, D.O.B:
Pharmacy *
Phone *
Please enter a valid phone number.
Bariatric Surgery Program
Seminar Date *

Month Day Year
Date
Preferred Surgeon

Dr. Smith Dr. Cudjoe Dr. Bonacci Dr. Pilkington
Additional Information
Prior Bariatric Surgery? (If so when)
Select the surgery your interested in:

Laparoscopic Adjustable gastric band Laparoscopic Sleeve Gastrectomy Laparoscopic Roux-en-y Gastric Bypass
Height: *
Weight: *
BMI (Body Mass Index)
Allergies: *
Latex allergy: *

Yes No

Date of Last *

	Date	Normal (If not Describe)	Describe
Pap Smear
Colonoscopy
Endoscopy
Mammogram
Physical

Do you suffer from any of these health problems presently or in the past? *

	Yes	No
Diabetes
Gestational Diabetes
Diabetic Neuropathy
Diabetic Retinopathy
Kidney Failure
High Blood Pressure
Congestive Heart Failure
Ischemic Heart Disease
Peripheral Vascular Disease
Angina
Leg Swelling
Leg Ulcer
DVT/Blood Clot
Pulmonary Embolism
Heart Disease
Heart Attack (MI)
Mitral Valve Prolapse
High Cholesterol
Aneurysm
Stroke TIA
COPD
Sleep Apnea
CPAP
Oxygen Use
Asthma
Pulmonary Hypertension
Cirrhosis
Fatty Liver
Heartburn/GERD
Stomach or Intestinal Ulcer
Barrett's Esophagus
Gall Stones
Cholecystectomy
Stress Incontinence
Irritable Bowel Syndrome
Crohn's Disease
Diverticulitis
Ulcerative Colitis
Hernia
Gout
Arthritis (Joint Pain)
Back Pain
Thyroid Problems
Bleeding Tendency
Anemia
Varicose Veins
Abdominal Apron Rash
AIDS/HIV
Vitamin/Mineral Deficiencies
Depression
Anxiety
Schizophrenia
Bi Polar
Eating Disorder
Cancer
Neurological Problems
Seizures/Convulsions
Auto Immune Disease
Mobility Problems

Family Medical History *

	Yes	No	Type
Cancer
Diabetes
Heart Attack
Heart Disease
Stroke/TIA
DVT/Blood Clot

Past Surgeries For You *
Current Diet (Diabetic, Regular, Other)
Coffee/Caffeine Intake (Cups Per Day)
Carbonated Beverage Intake (Cups Per Day)
Alcohol Use
Tobacco Use (If So, How Many Years)
Drug Use (Legal or Illegal, Frequency)
Medication List

Please list all medications as well as the dose, frequency, and the reason why you are taking it.

Medication (If none are taken just place "N/A" in each box of the first row.) *

	Drug Name	Dosage	Frequency	Method of Intake
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug

Do you use any of the following *

	Yes	No
Aspirin
Potassium
Steroids
Extended/Delayed Release
Non-Steroidal Anti-Imflammatory Drugs(NSAIDS-Motrin, Ibueprofen)
Blood Thinner (Coumadin,Plavix, Lovenox)

Please fill this form out to the best of your ability. We must have this information to best help you with your weight management goals. None of the information will ever be used in a negative or judgmental way but as a tool to personalize care to fit your individual needs. This, like all of your medical records, is kept confidential.
Weight History
Current Weight *
When Did You Start To Gain Weight? *
Do You Feel There Was A Trigger, Physical, Stress, Emotional That Contributed To Your Initial Weight Gain? If Yes, Please Explain. *
Is There Any Physical Reason You Fell You Are Struggling With Your Weight? *
Do You Feel There Is A Current Stressor Contributing To Your Weight? *
Previous Weight Loss Attempts
What was your lowest adult weight? How old were you? *
What was your highest adult weight? How old were you? *
What methods/ programs have you tried to lose weight? *
Which methods/programs worked best for you?
What is your ideal HEALTHY Weight
What would you like to weigh in:
6 months *
1 year *
Diet History
Who does the grocery shopping for your house?
Do you/they use a list when shopping?
Do you plan meals ahead?
Who do you usually eat with? (alone, spouse, family)
How often do you eat out in a week?
Do you often skip/miss meals?
What time of day do you struggle with your eating?
Do you have a hard eating too much of a certain type of food?
Do you eat fast? Finishing before others?
Do you eat to the point of feeling stuffed or overly full?
Do you crave certain foods often?
Do you recognize any non hunger triggers that make you want to eat? (emotional, boredom, stress)
Any food allergies?
Any food types that you dislike?
Do you usually focus on your food as you eat?
Do you eat well doing other things?(watching tv, driving, working)
Write down a typical day of eating in the box below.

Include drinks, condiments, snacks, and full meals. Also include portion sizes.
EXERCISE
What exercise equipment do you have available at home?
Do you exercise regularly? How often?
What exercise do you do? *
Do you want to be more active at this time? *
Are there barriers keeping you from exercising now? *
Are you physically active at your job? *
How much TV do you watch in a day? *
Mental Health History
Do you have any current Stressors? *
If you are comfortable can you explain them?
How do these stressors affect your weight lose?
Who is/are your main support person/people *
How does your family view your attempts to lose weight? *
On a scale of 1 to 10, where 1 is not important at all and 10 Is extremely important, how important Is it to you to change your weight and health right now? *
On a scale of 1 to 10 where 1 is not confident al all and 10 is extremely confident. how confident are you that you will be able to change your habits to healthier ones? *
Have you ever been abused emotionally, physically, mentally, sexually or in any other way? *
If your experienced any abuse, do you feel comfortable explaining?
Have you ever been treated for or diagnosed with A mental health illness like anxiety, depression or bipolar disorder?
Have you ever sought out counseling?
Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully, and check your response
Do you make yourself sick (throw up) because you feel uncomfortably full?
Do you worry you have lost control over how much you eat?
Would you say food dominates your life?
Do you eat a lot of food in a short time? If so do you feel out of control doing so?
Do you eat more than 25% (or a quarter) of your days food In the evening (after dinner)?
Do you wake up at night and feel like you have to eat to get back to sleep?
Social History
Household members and relationship to you? *
Is there stress at home? *
Your current or former job? *
What is your work schedule?
Is your job stressful?
Do you sit often during work?
What time do you usually go to bed?
What time do you wake up?
Do you sleep well, or stir through out the night?
Consent to Share Medical Information
On this date, I, name* , do hereby grant permission for my physician or his/her staff to discuss information regarding any and all treatment results to:
Name *
Relationship *
Name
Relationship
Name
Relationship
Name
Relationship
I understand this contact permission form is to be placed in my medical chart and used for the expressed purpose herin. *

Agree
Notice of Privacy Practices
I have read the above policy and agree to its terms *

Agree
Financial Policy
I have read the above policy and agree to its terms *

Agree
The undersigned Patient or legally authorized representative ("Agent") of the Patient acknowledges that he or she personally received a copy of the Great Lakes Surgical Associates Notice of Privacy Practices on the date indicated below.
All Patients: Authorization to Release Information & Assignment of Benefits

I authorize the release of any medical information necessary to process my medical service claims. I permit a copy of this authorization to be used in place of the original. I hereby authorize Great Lakes Surgical Associates (GLSA) to apply for benefits on my behalf for covered services rendered by my physician. I request that payments from my insurance company be made directly to GLSA. I certify that the information I have reported regarding my insurance coverage is correct. I understand I can revoke this authorization at any time by submitting a written request. I hereby state that all the above information is valid and accurate to the best of my knowledge.
Signature *
Date

Month Day Year
Information about Agent (attach appropriate documentation):
Agent
Title
Agent Documentation

Cancel of
Should be Empty:

Bariatric new patient

Patient Information

Bariatric Surgery Program

Additional Information

Medication List

Weight History

Previous Weight Loss Attempts

Diet History

Write down a typical day of eating in the box below.

EXERCISE

Mental Health History

Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully, and check your response

Social History

Consent to Share Medical Information

Notice of Privacy Practices

Financial Policy