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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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