Download APPLICATION DIRECTIONS In order for our staff at Center for

APPLICATION DIRECTIONS
In order for our staff at Center for Surgical Weight Management to process your application and
prepare for your surgery, we must have all documents requested in the application included and
completed. Avoid unnecessary delays by following these directions.
1.
Please print.
2.
Use black or blue ink.
3.
Include an enlarged front and back copy of your insurance card(s). Please provide copies
of ALL health insurance cards, even if that insurance does not cover weight loss surgery.
4.
Include a copy of your driver’s license/identification card.
5.
Complete every page of the application.
6.
Every item on the application should be answered with a “yes”, “no” or “not applicable”.
7.
Blanks will not be accepted.
8.
Explain all “yes” answers.
9.
Provide your primary care physician’s first and last name, address, phone number and fax
number.
10. Please keep a copy of your application for your records.
11. While you are completing the application, please write down any questions that you have.
This includes questions about the application, medical or surgical questions or questions
about the program.
CENTER FOR SURGICAL WEIGHT MANAGEMENT
*Patient History Forms. *Please fill out completely and fax to 678-312-6818*
Date:_____________________
Indicate date you attended the educational seminar ____________________ Height _________ Weight __________ BMI___________
(Title)
First Name
MI
Address
Last Name
Apt #
Phone #
City
Maiden Name
Suffix
Country
Zip Code
State
Email
Cell #
Work #
Social Security #
Fax #
Date of Birth
Employer
Age
Gender
Male
Female
Address
Occupation
Full-time
Emergency Contact
Phone
Part-time
Retired
Disabled
Relationship
Name of Primary Insurance Carrier
Name of Secondary Insurance (if applicable)
What is your current marital status?
Married
Single
Separated
Divorced
Widowed
Other
Which of the following best describes your ethnic origin?
Black/African-American
White/Caucasian
Asian/Oriental or Pacific Islander
Hispanic
Other _____________________
What category best describes your Highest Grade or Level of Education?
9 to 11 years
High School Graduate
Vocational/Technical Training
Attending College
College Graduate
Graduate Degree
Family Health/Weight History:
In this section, complete this chart to the best of your knowledge. If adopted and have no history of your biological family, place an X in this
box † Adopted.
Please check all that apply
Disease
Mother
Father
Maternal
Grandmother
Maternal
Grandfather
Paternal
Grandmother
Paternal
Grandfather
Morbid Obesity
Diabetes
Age: Diabetes Onset
High Blood Pressure
Stroke (age)
Heart Attack (age)
Cardiovascular Disease
Sleep Apnea
Cancer: Type (age of onset)
Death: List age and cause
Has one of your relatives ever had Bariatric (weight reduction) surgery?
Yes
No
Relationship to you:
Patient Last Name ____________________________ Date of Birth _____________________
Page 1
Medication Information:
Please list all prescribed and over-the-counter medications that you are currently using (include vitamins and herbal supplements):
Prescription Medications
Dose
Times per Day
Purpose
Over-the-counter Medications
Dose
Times per Day
Purpose
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1.
2.
3.
4.
5.
6.
Allergy Information:
Please list any known allergies:
What allergic reaction did you have?
Pharmacy Information:
Pharmacy
Phone Number:
Address
Health Information:
Cardiac:
Coronary Artery Disease
(Heart Attack)
Yes
Yes
No
No
Year Diagnosed:
Year Diagnosed:
If yes, Treatment
Physician:
Physician:
Elevated cholesterol/triglycerides
Chest Pain
Valvular Heart Disease
Yes
Yes
Yes
No
No
No
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Physician:
Physician:
Physician:
Yes
Yes
Yes
No
No
No
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Physician:
Physician:
Physician:
Yes
Yes
Yes
No
No
No
Year Diagnosed:
When:
Year Diagnosed:
Physician:
Where:
Physician:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
When:
Physician:
Physician:
Physician:
Physician:
Physician:
Physician:
Physician:
Physician:
Physician:
Where:
Yes
Yes
Yes
Yes
No
No
No
No
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Physician:
Physician:
Physician:
Physician:
(e.g. Mitral Valve Prolapse, Mitral Valve Regurgitation, etc.)
Rheumatic Fever
Heart Murmur
Heart Arrhythmia
(e.g. irregular heart beat)
Hypertension
Did you have a stress test?
Congestive Heart Failure
Pulmonary:
Asthma
Pneumonia
COPD (Emphysema)
Tuberculosis
Observed Sleep Apnea
Loud Snoring
Shortness of breath
History of respiratory infections
Diagnosed Sleep Apnea
Did you ever have Pulmonary Function Tests?
Do you use CPAP/BiPAP?
Endocrine:
Diabetes Mellitus
Hyperthyroid
Hypothyroid
Renal (Cushings)
Patient Last Name ____________________________ Date of Birth _____________________
Page 2
Gastroenterology:
Reflux Disease (Heartburn)
Peptic Ulcer Disease
Gall bladder Disease
Liver Disease
Other:
Yes
Yes
Yes
Yes
No
No
No
No
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Cancer:
Type/Organ(s) Effected:
Physician:
Physician:
Physician:
Physician:
Physician:
Treatment:
Peripheral Vascular Disease:
Arterial Vascular Disease
Pulmonary Embolism
Phlebitis
Leg or Ankle Swelling
Blood Clots
Venous Statis
Varicose Veins
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Physician:
Physician:
Physician:
Physician:
Physician:
Physician:
Physician:
Renal:
Kidney Disease
Urinary Stress Incontinence
Kidney Stones
Yes
Yes
Yes
No
No
No
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Physician:
Physician:
Physician:
Central Nervous Systems:
Seizure Disorders
CVA (Stroke)
Metabolic Disorders
Migraine Headaches
Other:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Physician:
Physician:
Physician:
Physician:
Physician:
Yes
No
Orthopedic:
Lower Back Pain
Diagnosed Osteoarthritis/DJD
Neck
If yes, joint(s) involved?
Ankles
Shoulders
Feet
Back
Heels
Hips
Hands/wrist
Knees
Neck
Ankles
Shoulders
Feet
Back
Heels
Hips
Hands/wrist
Knees
Painful Joints
(without Osteoarthritis/DJD)
Gout:
If yes, list of joint(s) involved:
Other Medical Disorders:
Psychiatric Disorders:
Depression
Schizophrenia
Eating Disorders
If yes, what type?
Yes
Yes
Yes
No
No
No
Year Diagnosed:
Year Diagnosed:
Year Diagnosed:
Physician:
Physician:
Physician:
Suicide attempt
Other:
Yes
Yes
No
No
Year Diagnosed:
Physician:
Patients Physician Information:
Name of Primary Care Physician:
Address:
Phone Number:
Fax Number:
Please list any Physicians you are currently seeing:
Name of Physician:
Address:
Phone Number:
Fax Number:
Name of Physician:
Address:
Phone Number:
Fax Number:
Patient Last Name ____________________________ Date of Birth _____________________
Page 3
Previous Surgery Information:
If applicable, please indicate if your surgical procedure was done laparoscopic or an open procedure:
Type of Surgery:
Type of Surgery:
Type of Surgery:
Type of Surgery:
Type of Surgery:
Type of Surgery:
Reason:
Reason:
Reason:
Reason:
Reason:
Reason:
Year:
Year:
Year:
Year:
Year:
Year:
Have you ever had previous weight loss surgery?
If yes, please explain:
Yes
No
Have you ever had any trouble with Anesthesia?
If yes, please explain what occurred:
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
Previous Medical History:
Have you ever had a blood transfusion?
Do you have any problems with bleeding or clotting?
Have you ever had any broken bones of the face?
Have you ever had any broken bones of the back/neck?
Obstetrical/Gynecological:
Do you have a history of breast cancer?
Have you ever had a hysterectomy?
Were the Ovaries removed?
Have you ever had a Cesarean Section:
Have you ever had a tubal ligation?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
If yes, please indicate whether
Vaginal
Abdominal
If yes, please indicate how many ____________
If yes, indicate how the procedure was done
Open
Laparoscopic
If applicable, please indicate the number of pregnancies to term _____________
Please indicate whether you are
Pre-menopausal
Post-Menopausal
Smoking/Drug/Alcohol History:
Do you currently use tobacco?
Have you ever used tobacco?
Yes
Yes
No
No
If you answered yes to the above questions:
Cigarettes
x What type of tobacco uses?
x What age did you start tobacco use? _______________
x How many years have you used tobacco? _______________
Cigars
Pipe
½ pack or less
between ½ to 1 pack
How much do/did you usually smoke per day?
x If applicable, what age did you quit smoking? _______________
Yes
Yes
Do you currently use alcohol?
Have you ever had a problem with alcohol in the past?
If yes, please indicate when and how long:
Have you ever used any drugs in the past?
x If so, which drugs?
x If yes, how long ago?
6 months or less
between 1½ to 2 packs
2½ or more packs
No
No
If you answered yes to the above questions:
Wine
Beer
Liquor
x What type(s) of alcohol did/are you drinking?
x Please indicate how many drinks you currently have or have drunk each day?
Please indicate other drugs that you currently use:
x How long have you been using?
Chew/Snuff
Mixed Drinks
less than 2
Other ________________
2-5
6-10
11 or more
Marijuana
Cocaine
Heroin
Amphetamines
Other ____________________
less than 6 months
6 months – 1 year
more than 1 year
Yes
No
6 months – 1 year
more than 1 year
Patient Last Name ____________________________ Date of Birth _____________________
Page 4
Have you been on a 3-6-month physician supervised diet within the last year?
If yes, please provide supporting documentation. (A copy of each office visit)
Yes
No
Please list the history of any food or liquid diets that you have tried in an attempt to lose weight over the past five years. Please be as complete as
possible. *Do not leave any blanks.
Please check and provide specific information for all diets that apply. Please submit documentation where applicable
that supports diet attempts.
Medically Supervised Diet
Programs
Number of
Attempts
When
(dates)
Length of
Time
Weight Loss
Weight
Regained
MC/Clinic/City
Medi-fast
Opti-fast
Fen/Phen
Redux
Meridia
Xenical
Behavior Modification
Hypnosis
Accupuncture
Inpatient Weight Clinic
Injections
Diet by Registered Dietitian
Other
Other
Non-Physician/Dietitian Supervised Diet Programs
Weight Watchers
Nutri-Systems
Jenny Craig
TOPS
The Zone Diet
Atkins
Slim Fast
The South Beach Diet
The Pritikin Principle
Scarsdale
Other
Other
Miscellaneous Diets
Low Calorie
Low Fat
High Protein
Self Imposed Fasts
Richard Simmons
Susan Powter
Herbal Life
Cambridge
Metabolife
Mayo Clinic Diet
Other
Other
Diet Pills
Accutrim/Dexatrim
Diurex
Phentermine / Adipex
Other
Other
Exercise
Health Club
DVD Tapes
Walking
Swimming/Water Exercises
Other
Other
Patient Last Name ____________________________ Date of Birth _____________________
Page 5
Bariatric Pre-Surgery Encounter Form
Date:
Name:
Date of birth:
Height:
Weight:
Co-morbidities ( Select ONE statement for each category that best describes you)
*If you have any questions regarding this form, please ask for assistance.
High Blood Pressure
No indication of high blood pressure
Borderline high blood pressure, no medication
Diagnosis of high blood pressure, no medication
Treatment with one medication
Treatment with multiple medications
Poorly controlled by medications, organ damage
Lipids (Hyperlipidemia)
Not present
Present, no treatment required
Controlled with lifestyle change (diet and exercise)
Controlled with one medication
Controlled with multiple medications
Not controlled
Congestive Heart Failure
No indication or symptoms of congestive heart failure
Symptoms with more than ordinary activity
Symptoms with ordinary activity
Symptoms with minimal activity
Symptoms at rest
Gout (Hyperuricemia)
No symptoms of gout
Gout, no symptoms
Gout requiring medications
Gout causing pain in the joints
Gout causing destructive joints
Gout causing disability, unable to walk
Chest Pain
No chest pain symptoms
Chest pain with extreme exertion (running, etc.)
Chest pain with moderate activity
Chest pain with minimal activity or at rest
Unstable chest pain
Previous heart attack
Peripheral Vascular Disease (PVD)
No symptoms of peripheral vascular disease
Diagnosis of PVD, but no symptoms
Diagnosis of PVD, on medication
Transient Ischemic Attack, pain at rest
Procedure done for PVD
Stroke or loss of body part due to PVD
Lower Extremity Edema
No symptoms of lower extremity edema
Lower extremity edema at times, not requiring treatment
Symptoms requiring treatment, diuretics, elevation, or hose
Ulcers of the lower extremities
Disability, decreased function, past hospitalization
Diabetes
No symptoms or evidence of diabetes
Elevated fasting blood sugar or pre-diabetes
Diabetes controlled with oral medications (pills)
Sleep Apnea
No symptoms of sleep apnea
Sleep apnea symptoms (excessive snoring)
Diagnosed sleep apnea (no oral appliance)
Sleep apnea requiring an oral appliance such as CPAP
Sleep apnea with hypoxia or oxygen dependent
Sleep apnea with complications (pulmonary hypertension, etc.)
Obesity Hypoventilation Syndrome
No symptoms of obesity hypoventilation syndrome
Low oxygen level on room air
Severe low oxygen level
Pulmonary hypertension
Right heart failure
Right heart failure – left ventricular dysfunction
Pulmonary Hypertension (PH)
No symptoms of pulmonary hypertension
Symptoms of PH (tiredness, shortness of breath, dizziness, fainting)
Confirmed diagnosis of PH
Well controlled on anticoagulants or Calcium Channel Blocker
Stronger medications or oxygen required
Need or have had lung transplant
Abdominal Skin
No symptoms
Diabetes controlled with insulin
Diabetes controlled with oral medications and insulin
Diabetes with severe complications (neuropathy, blindness)
Asthma
No symptoms of asthma
Mild symptoms, no medication
Symptoms controlled with oral inhaler (such as albuterol)
Well controlled with ongoing daily medication
Not well controlled, requiring steroids
Hospitalized within the last 2 years, history of intubation
GERD
No symptoms of GERD (reflux)
Intermittent of variable symptoms, no medication
Intermittent medication
Regularly scheduled medication for reflux
In need of anti-reflux surgery, or have had anti-reflux surgery
Cholelithiasis (Gallstones)
No indication of gallstones
Gallstones with no symptoms
Gallstones with occasional symptoms
with severe symptoms OR previously had gallbladder
Gallstones
removed
with complications requiring immediate surgery (prior to
Gallstones
Gastric Bypass)
of cholecystectomy (gallbladder removed) with ongoing
History
complications not resolved
Liver Disease
No indication of liver disease
Enlarged liver (modest), normal liver function test
Enlarged liver (greater), abnormal liver function test
Enlarged liver with mild inflammation and fibrosis
Cirrhosis of the liver
Liver failure, transplant needed
Back Pain
No symptoms of back pain
Occasional symptoms not requiring medical treatment
Symptoms requiring non-narcotic treatment
Symptoms requiring narcotic treatment
Surgical intervention done for back pain or recommended
Failed previous surgical intervention with existing symptoms
Musculoskeletal Disease
No symptoms of musculoskeletal disease
Pain with community ambulation
Non-narcotic treatment required
Pain with household ambulation
Surgical intervention required (arthroscopy)
Awaiting joint replacement or have had joint replacement
Fibromyalgia
No indication of fibromyalgia
Treatment with exercise
Treatment with non-narcotic medications
Treatment with narcotics
Treatment with narcotics and surgical intervention done or
recommended
Disabling, treatment not effective
Polycystic Ovarian Syndrome (Females only)
No indication of Polycystic Ovarian Syndrome (PCOS)
Symptoms of PCOS, no treatment
OCP’s or anti-androgen prescription
Metformin or TZD
Combination therapy
Infertility
Irritation to abdominal skin folds
Skin fold large enough to interfere with walking
Recurrent cellulites or ulceration of skin folds
Surgical treatment required
Menstrual Irregularities (not PCOS)
No indication of menstrual irregularities
Irregular periods
Heavy periods
Absence of periods
Prior total hysterectomy
Psychosocial Impairment
No impairment
Mild impairment, but able to perform all primary tasks
Moderate impairment, but able to perform most tasks
Moderate impairment, unable to perform some tasks
Severe impairment, unable to perform most tasks
Severe impairment, unable to function
Depression
No symptoms of depression
Mild and episodic, not requiring treatment
Moderate, may require treatment
Moderate, requires treatment
Severe, requiring intensive treatment
Severe, requirement hospitalization
Confirmed Mental Health Diagnosis
None
Bipolar disorder
Anxiety/panic disorder
Personality disorder
Psychosis
Alcohol Use:
None
Rare
Occasional
Frequent
Tobacco Use:
None
Rare
Occasional
Frequent
Substance Abuse (Prescription or Illegal)
None
Rare
Occasional
Frequent
Stress Urinary Incontinence
No symptoms
Minimal and occasional
Frequent but not severe
Daily occurrence, requires sanitary pad
Disabling
Operation ineffective
Pseudotumor Cerebri
No symptoms of pseudotumor
Headaches with dizziness, nausea, and/or pain behind eyes
Headaches with visual symptoms and/or controlled with diuretics
MRI confirming Pseudotumor Cerebri, well controlled with diuretics
Well controlled with stronger medication
Requires narcotics or has had (or needs) surgical intervention
Abdominal Hernia
No hernia
Hernia with no symptoms, no prior operation
Hernia with symptoms
Successful hernia repair
Recurrent hernia or size greater than 15cm
Chronic evisceration through large hernia with complications or
multiple failed hernia repairs
Functional Status
No impairment of functional status
Able to walk 200 feet with assistance device (cane or crutch)
Cannot walk 200 feet with assistance device
Requires wheelchair
Sleep Apnea Assessment for Bariatric Surgery
Pt. Name:
Phone Number:
Date:
Medical/ Sleep History/Symptoms (check appropriate boxes):
Excessive Sleepiness
AM Headaches
High Blood Pressure
Snoring
Insomnia
Diabetes
Never feel rested/ always tired
Lung Disease
Depression
Apnea
Asthma
CPAP Compliance problems
Epworth Sleepiness Scale:
0= would never doze
1= slight chance of dozing
Chance of dozing
_________
_________
_________
_________
_________
_________
_________
_________
2= moderate chance of dozing
3= High chance of dozing
Situation
Sitting and reading
Watching TV
Sitting inactive in a public place (a theater)
As a passenger in a car for an hour without a break
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Lying down to rest in the afternoon when circumstances permit
Technologist’s Recommendations
Signs and symptoms of Sleep Apnea; recommend a split night sleep study.
Diagnosed with OSA, non-compliance with CPAP; recommend a split night sleep study with BIPAP.
Patient on CPAP; recommend switch to Auto-titrating PAP device.
Respiratory disorders, with diagnosed OSA; recommend consult with Georgia Pulmonary Group.
Additional information:
_____________________________
Technician Signature
_____________________
Date:
AUTHORIZATION FOR RELEASE/DISCLOSURE
OF PROTECTED HEALTH INFORMATION
I hereby request and authorize Center for Surgical Weight Management to release records as described below for the
purpose of:
 Continued Treatment
 Insurance
 Attorney
 Personal
 Other Bariatric Surgery
Patient’s Full Name: (print)
Date of Birth:
Social Security #:
Current Address:
Home Phone:
Medical Record #:
Work Phone:
To release the medical/financial records checked below to:
Organization:
Address:
Fax Number:
Phone Number:
by Mail
 by Fax to #:______________________
 to communicate verbally with: __________________________  to obtain copies from: _______________________
This Authorization applies to the information checked below for the date(s) of service on: _____________________________
 2 Year Weight History
 Face Sheet
 Pathology Report
 5 Year Weight History
 Fetal Monitor Strips
 Pathology Slides/Blocks
 Discharge Summary Reports
 Financial Record
 Physical/Occupational Therapy Notes
 Electrocardiogram (ECG/EKG)
 Laboratory Test Results (include TSH)
 Radiology Films
 Emergency Department Record
Office Visit Records
 Radiology Reports
 Entire Medical Record
Operative Report
Other, please specify below
Please specifically describe other required information: _________________________________________________________
I understand that the information used or disclosed pursuant to this Authorization may be subject to redisclosure by the
recipient of the information and may then no longer be protected by the federal privacy regulations. I understand that I may
revoke this Authorization at any time by presenting my revocation in writing on the Gwinnett Hospital System Authorization
Revocation form, except to the extent that Gwinnett Hospital System has taken action in reliance on this Authorization. I
further understand that this Authorization is specific to the information checked above, for the date of services indicated, and
for the purpose written above. I understand that this disclosure may include psychiatric, drug/alcohol, and/or HIV testing
results, and/or AIDS related information. Gwinnett Hospital System shall not condition treatment on the receipt of this
Authorization.
This authorization and/or request to release information from my protected health information (PHI) is fully understood and is
made voluntarily on my part and includes faxing of PHI. I understand that a photostatic or faxed copy of this authorization is
as valid as the original.
I further understand that this Authorization is valid for a period of one (1) year from today’s date and will expire at that time
unless an earlier date is written here_______________________________________________.
X
Patient’s or Legal Representative’s Signature
Today’s Date
If signing as legal representative for the patient, signee must complete GHS form #190000.