Download Our team at My New Beginning is here to support you through every

To find out if you’re a candidate for weight loss surgery, please
complete the enclosed information and return to our clinic.
If you have questions, call us at 214.324.6127.
Our team at My New Beginning is here to
support you through every step of the journey.
My New Beginning Surgery Weight Loss Clinic
1151 N. Buckner Suite #308
Dallas, Texas 75218
Office: 214.324.6127 | FAX 214.324.6627
PATIENT INFORMATION
LAST NAME, FIRST, MIDDLE
RACE
❑
MALE
❑
FEMALE
STREET ADDRESS
AGE
DATE OF BIRTH
CITY, STATE, ZIP
SOCIAL SECURITY
HOME /CELL PHONE
OCCUPATION
WORK PHONE
EMPLOYER
EMAIL ADDRESS
HOW DID YOU HEAR ABOUT US?
PRIMARY CARE PHYSICIAN
HIGHEST LEVEL
OF EDUCATION:
ADDRESS
PHONE/FAX:
RESPONSIBLE PARTY INFORMATION
LAST NAME, FIRST, MIDDLE
SOCIAL SECURITY
DATE OF BIRTH
RELATIONSHIP TO PATIENT
STREET ADDRESS
CITY, STATE, ZIP
HOME /CELL PHONE
WORK PHONE
EMPLOYER
INSURANCE INFORMATION
INSURANCE NAME
POLICY t
GROUP t
PHONE
POLICY HOLDER & DOB
INSURANCE NAME
POLICY t
GROUP t
PHONE
POLICY HOLDER & DOB
INSURANCE NAME
POLICY t
GROUP t
PHONE
POLICY HOLDER & DOB
IN CASE OF EMERGENCY NOTIFY (Other Than Responsible Party)
NAME
ADDRESS, IF POSSIBLE
PHONE
__________ Initials
PATIENT INFORMATION PACKET – P. 2
PREVIOUS HOSPITALIZATIONS/
SURGERIES/SERIOUS ILLNESSES
Have you had a previous weight loss surgery?
 Yes ❑ No
Have you or any of your family members
Explain prior weight loss surgery (where/when/type):
___________________________________________
___________________________________________
Other Previous Surgeries:
___________________________________________
had any type of problem with anesthesia?
 Yes ❑ No
FAMILY MEDICAL HISTORY (parents, grandparents,
brothers, sisters)
PATIENT SOCIAL HISTORY
Please indicate who has or has had these health problems:
Marital Status
 Single
❑ Married
 Divorced
❑ Widowed
❑ Separated
Obesity: _________________________________
Lung Disease, Asthma or Emphysema: _________
Patient Lives
Diabetes: ________________________________
 Alone ❑With Family ❑Other: _____________
Kidney Disease: ___________________________
Use of Alcohol
High Blood Pressure: _______________________
 Never ❑ Rarely ❑ Moderate
 Daily
Use of Tobacco
 Never ❑ Previously, but quit __________
 Current packs per day: ______
Use of Drugs
Bleeding Tendency or Blood Disorder: __________
Heart Disease (indicate what type):
________________________________________
________________________________________
Breast Cancer: ____________________________
 Never
High Blood Cholesterol: _____________________
 Type/Frequency: _______________
Colon Cancer: ____________________________
Adaptive Self-Care aids
Liver Problems: __________________________
 None
❑Cane
 Wheelchair
❑Walker
❑ Oxygen
 Other: ________________________
WEIGHT HISTORY
Current Height: _________ ft. ________ in.
FAMILY SUPPORT
Current Weight: _________ pounds
How does your support person (family) feel
What was your approximate weight for each of the
about you having this type of surgery?
BIOPSYCHOSOCIAL
Religion: _______________________________
past five years?
Year
Weight
Year
Weight
20 ____
_______
20 ____
_______
20 ____
_______
20 ____
_______
20____
_______
Are there religious needs we may help you
with during your hospital stay? ❑Yes ❑No
__________ Initials
PATIENT INFORMATION PACKET – P. 3
Please list all diets, diet pills, diet programs and
exercise programs that you have attempted:
Pulmonary embolus (blood clot in lung)

C O PD

Emphysema

Bronchitis: When: _____________

Sleep Apnea
 CPAP
 Snore
❑ BIPAP
❑ Stop Breathing
When and where was the sleep study done?
Comments: _____________________________
REVIEW OF SYMPTOMS
Endocrine
Please indicate any personal history below:
Genitourinary

None

Frequent Urination

Kidney Stones

Kidney Failure

Nephritis

Urinary Tract Infections

None

Thyroid Disease
When diagnosed: _____________________
Medication: __________________________

Diabetes ❑ Insulin ❑ Oral Agent
Date of onset: ________________________

Last UTI: ___________________
Diabetic Diet Instruction
Calorie Level: ________________________

Incontinence or Dribbling

Pain with Urination

Leakage of urine with coughing, laughing
Comments: _____________________________
or sneezing

On Dialysis
Psychological
Respiratory

None

Nervousness
None

Anxiety

Cough/Wheezing

Depression

Shortness of breath


frequent
Medication: _________________
❑
on exertion

If you walk at a fairly good pace, how far can you
walk before being out of breath? _________
Ever hospitalized for asthma? ❑ Yes ❑ No
On Oxygen? ❑ Yes ❑ No
Hospitalization for emotional problem
When/Where? __________________
Name of doctor treating/has treated you:
l/min
__________ Initials
PATIENT INFORMATION PACKET – P. 4
Is your physician aware that you are interested in
having bariatric surgery?
Comments: _____________________________
Cardiovascular

None

Angina

Palpitations

❑ Yes ❑ No
Joint Replacements
Which ones? __________________________

Ankle and foot pain

Fibromyalgia

Multiple Sclerosis

Rheumatoid Arthritis
Comments: ______________________________
Can you lie flat on your back?
❑ Yes ❑ No
If no, what happens when you lie down?
Neurological

None

Stroke

Sleeping difficulty

Pain in neck, chest, arms

Heart Attack

Abnormal Electrocardiogram

Irregular Heartbeat
Dizziness, Vertigo


High Blood Pressure
Numbness, tingling feelings, weakness.

What kind? __________________________
Where? _____________________________
How long? ___________________________

Tremors
Medication: __________________________

Convulsions/Seizures

Congestive Heart Failure

High Cholesterol/ Triglycerides
When and what caused it? ______________

How long? ___________________________

Blood clots in legs

IVC filter?

Recent ECG

Pacemaker

Heart Cath
Date:_________________
Comments: _____________________________
Musculoskeletal

None

Pain/Swelling in Joints

Degenerative Joint Disease

Arthritis

Low back pain/back injury

Ankle and foot pain
Loss of consciousness
When & why? _________________________

Pseudotumor Cerebri
Comments: ______________________________
Gastrointestinal

None

Indigestion

Nausea/Vomiting

Diarrhea

Constipation

GERD

Pain with bowel movement


Blood in stools
Hemorrhoids
Medication: _______________
__________ Initials
PATIENT INFORMATION PACKET – P. 5

Irritable Colon

Colitis

Gallbladder Disease

Gallbladder Removal

Recent Colonoscopy

Recent EGD or “Scope”

Ulcers

History of H.pylori

Liver problems

Hepatitis

Crohn’s disease
Allergies to Medications and reaction to each:
❑ No known allergies
Allergies to Food:
Comments: _____________________________
Latex or other Allergies: ❑ No latex allergy
WHAT ARE YOUR EXPECTATIONS OF
BARIATRIC SURGERY?
Other Conditions

None

HIV/AIDS

Bleeding Disorder

Blood Clotting Disorder

Other conditions we should be aware of?
HOW MUCH WEIGHT DO YOU EXPECT TO LOSE?
WHICH PROCEDURE DO YOU PREFER:
 Roux-en-Y Gastric Bypass
 Sleeve Gastrectomy
 Lap-Band
MEDICATION LOG
 Medication List Added Separately
 Are you on any blood thinners or steroids, e.g. Prednisone?
DATE RX
MEDICATION
❑Yes ❑
DOSAGE
No
FREQUENCY
Your pharmacy’s name and phone number:
__________ Initials
PATIENT INFORMATION PACKET – P. 6