Download PATIENT PROFILE FORM - UF Health Jacksonville

PATIENT PROFILE FORM
Dr. _______________________
PATIENT INFORMATION
TODAY’S DATE___/___/___
Name_________________________________________________________________________
First
MI
Last
Address_______________________________________________________________________
Street
City
State Zip
Home Phone __________________________Cell Phone ________________________________
(WHICH PHONE NUMBER IS BEST NUMBER TO REACH YOU?)
Date of Birth___/___/______
____ Male
____ Female
Social Security Number ______________________
____ Single
____ Married
____ Widowed
Employer _________________________________________Work Phone__________________
Email Address _____________________________________
SPOUSE INFORMATION
Name ________________________________________________________________________
First
MI
Last
Date of Birth___/___/___
Social Security Number ______________________
Employer______________________________________________________________________
IF PATIENT IS A MINOR
Father’s Name _________________________________________________________________
First
MI
Last
Date of Birth ___/___/___
Social Security Number ______________________
Employer _______________________________________ Work Phone ___________________
Mother’s Name _________________________________________________________________
First
MI
Last
Employer _______________________________________ Work Phone ___________________
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CONTACT INFORMATION
For emergency, list relative not in the same household _________________________________
Relationship _________________________ Phone ____________________________________
Address_______________________________________________________________________
Who may receive your health or financial information? ________________________________
How did you hear about the UF Health Weight Loss Surgery Institute?
___ Family Member ___ Friend ___ Newspaper ___ Primary Physician ___ Flyer ___ Other
INSURANCE INFORMATION
PRIMARY INSURANCE
Insurance Company _______________________________________ Phone_________________
Address _______________________________________________________________________
Group #____________________________ Policy # ____________________________________
Name of Policy Holder ___________________________________________________________
Relationship to you: ___Self ___ Spouse ___Child ____Other (please specify) ______________
SECONDARY INSURANCE
Insurance Company _______________________________________ Phone# _______________
Address _______________________________________________________________________
Group #____________________________ Policy # ____________________________________
Name of Policy Holder ___________________________________________________________
Relationship to you: ___Self ___ Spouse ___Child ____Other (please specify) ______________
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PATIENT HISTORY QUESTIONNAIRE
The information requested in this questionnaire is VERY important. To provide the best care,
and to obtain your insurance approval, we must have complete answers. PLEASE be thorough.
Name_________________________________________________ Date___________________
Age________ Occupation________________________________ Circle One: Male Female
Circle one of the following: Lap Banding
Open Bypass
YOUR MEASUREMENTS
Lap Bypass
WEIGHT HISTORY
Please estimate as closely as possible for all that apply.
Measurement
YOUR
Measurement
Life Event
Age
Height
Birth
Actual Body Weight
Start of High School
Target Weight
Marriage
Body Frame
(circle one)
Pregnancy(s)
BMI
Small
Waist
Medium
Hips
Large
Neck
Were you obese as a child?
Weight
Lowest Weight in
Past 5 Years
Lowest Weight in
Past 5 Years
Highest Weight in
Past 5 Years
YES
or
NO
(please circle one)
Number of years 100 pounds over healthy weight: ____________________________________
Approximate age when you first seriously dieted: _____________________________________
In your own words, please describe what you hope to accomplish and how you believe your life
will change by losing weight: ______________________________________________________
______________________________________________________________________________
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WEIGHT MANAGEMENT HISTORY
This form is submitted to your insurance company with your letter of medical necessity.
Approval or denial of your request for surgery depends on meeting the criteria put forth by
your insurance company. Failure of multiple attempted dietary programs is a standard
requirement. Please fill out in detail.
Doctors who are
following or have
followed your
weight problems:
Diet programs
your doctor has
you trying or has
had you try:
Weight
Loss
Weight
Regained
Length of
Program
Estimated
Cost
Please provide to the best of your knowledge any weight loss program you have tried over the
years. This information must be completed and is vital to your surgery authorization. Do your
best to provide as much information as possible.
Program
Year
Weight
Loss
Weight
Regained
How
many
times
Length
of
Estimated
Program Cost
Weight Watchers
TOPS
Overeaters Anonymous
Jenny Craig
NutriSystem
LA Weight Loss
Quick Weight Loss Center
Behavior Modification
Jaws Wired
Appetite Suppressant Pills
Shots
Hypnosis
Hoodia
Set for Life
4
200 Plus – Dana Thornock
How to lower your fat
thermostat
Herbal Life
Slim Fast
Slim for Life
Richard Simmons
Acupuncture
Fad Diets (please specify)
Self-Imposed Diet Attempts
Other (please list)
PHYSICAL EXERCISE
Program
Time
Spent
Weight
Loss
Weight
Regained
Length of
Program
Estimated
Cost
Bicycling
Jogging
Walking
Swimming
Spa Memberships
Aerobic
Video Tapes
Health Rider
Home Gym Equipment
Curves
5
FOOD PREFERENCES
Eating Habits: (please circle all that describe your current eating habits)
Scheduled regular meals
No set schedule/grazer
Meat & potatoes type
Sweets
Snacks
Junk food
Fast food
Large/multiple portions
Eat on the go
Purging
Emotional eater
Eat at night
Binge/compulsive eater
History of bulimia
History of anorexia
Do you eat while doing other things? ___________ Do you eat without thinking? ___________
Do you meal plan in advance? _________________ Do you have food cravings? ____________
How often do you eat away from home? ________ What kind? _________________________
Food Frequency Check: (please indicate how many servings a day you consume)
____ Sweets
____ Ice cream
____Sweetened beverages
____ Vegetables
____ Fruit
____ Milk
____ Cakes
____ Cookies, pie
____ Cheese/yogurt
____ Alcohol
____ Fast food
____ Meat/meat alternatives
____ Water
____ Bread/grain products
____ Snacks, chips, crackers, etc.
____ Restaurant dining
____ Caffeine drinks (hot & cold)
____ Fried/high-fat food/French fries, etc.
____ Added fats/salad dressing, butter, etc.
____ Convenience foods/frozen dinners, deli meals, pizza and take out, etc.
Comfort Foods: _________________________________________________________________
Food Allergies: _________________________________________________________________
Food Intolerances: ______________________________________________________________
Dietary Supplements: ____________________________________________________________
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WEIGHT-RELATED ILLNESSES
Have you had, or do you have any of the following illnesses or symptoms?
Heart Disease
Yes
No
High Cholesterol
Yes
No
High Blood Pressure
Yes
No
Diabetes
Yes
No
Asthma
Yes
No
Sleep Apnea Syn.
Yes
No
Year diagnosed ___________________
(Circle all that apply to you)
M.I. (myocardial infarction)
CABG (coronary artery bypass graft)
Abnormal EKG
Stress Test
Palpitations
Year diagnosed ___________________
List Medications: __________________
________________________________
High Triglycerides
Yes
No
Year diagnosed ___________________
Average pressure _________________
List Medications: __________________
________________________________
Dietary Restrictions: _______________
________________________________
Year diagnosed ___________________
Gestational: Yes
No
Neuropathy: Yes
No
Controlled with:
Diet
Insulin
Oral Medication
List Medications: __________________
________________________________
Year diagnosed ___________________
ER Visits in the last 2 years __________
Hospitalizations in the last 2 years ____
Steroid used in the last 2 years _______
Year diagnosed ___________________
Last Sleep Study ___________________
CPAP used
Yes
No
Morning headaches Yes
No
Daytime drowsiness Yes
No
Restless sleep
Yes
No
Snoring
Yes
No
Awakenings at night Yes
No
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Coughing or choking at night
Shortness of breath
Yes
Yes
No
No
Heartburn/Esophagitis
Yes
No
Belching acid/sour on back of throat Yes
Gallbladder
Yes
Leakage of urine w/laughing,
Yes
coughing, sneezing
Low Back strain/pain/sciatica
Yes
No
No
No
Pain in hips/knees/ankles/feet?
Yes
No
Weight related injuries & trauma
Yes
No
Varicose Veins
Thyroid Disease
Yes
Yes
No
No
No
Can walk on level ground
Yes
No
Long: _______________________
How many stairs: __________________
Year diagnosed ____________________
Upper GI Series
Yes
No
Endoscopy
Yes
No
Medications ______________________
Frequency of use ___________________
UGI Endoscopy ordered ______________
How diagnosed? Ultrasound exam_____
Wear pads frequently? _______________
Seen by Chiropractor? _______________
Seen by Orthopedic Surgeon? _________
Seen by Family Doctor? ______________
Medications taken __________________
__________________________________
Frequency taken____________________
__________________________________
Seen by Chiropractor? _______________
Seen by Orthopedic Surgeon? _________
Seen by Family Doctor? ______________
Medications taken __________________
__________________________________
Frequency/dose taken________________
__________________________________
__________________________________
__________________________________
__________________________________
Do you have swelling? ________________
Medications? Yes
No
Name of Medication: _________________
__________________________________
__________________________________
__________________________________
__________________________________
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SLEEP HISTORY
How many hours sleep do you get at night? ________________________________________
What is it that keeps you up at night? _____________________________________________
____________________________________________________________________________
Would you consider the equality of your sleep is:
Good
Fair
Poor
If your sleep is a major problem to you or your partner, would you be prepared to have a
sleep study performed now and after you lose weight? Yes
No
SYMPTOMS OF SLEEP APNEA
0 = WOULD never DOZE
1 = SLIGHT chance of dozing
2 = MODERATE chance of dozing
3 = HIGH chance of dozing
SITUATION
Chance of Dozing (circle the
number corresponding to the
key above
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting, inactive in a public place (e.g., a
theater or a public meeting)
0
1
2
3
As a passenger in a car without a break
0
1
2
3
Lying down to rest in the afternoon when
circumstances permit
0
1
2
3
0
1
2
3
0
1
2
3
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes
in the traffic
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PAST MEDICAL HISTORY
Are you allergic to any medications, foods, or materials?
Yes
No
______Penicillin _____Sulfa _____Latex
Other________________________________________________________________
Have you taken diet pills in the last two weeks?
Yes
No
Yes
No
Are you taking birth control pills or any other Estrogen/Progesterone?
Replacement? (Patients to stop taking drug one month prior to surgery)
Are you taking Aspirin or Ibuprofen for joint or back pain?
(Patient to stop taking drug two weeks prior to surgery)
***Consult prescribing physician if you have any questions.
MEDICATIONS
DRUG NAME
DOSAGE
TREATMENT FOR
COST TO YOU
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Please list below all serious illnesses and hospitalizations you have experienced in adulthood:
(use back of paper if more space is needed)
Major Illness
Date
Treatment
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Major Surgery
Date
Open or Laparoscopic
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Please identify which of the following childhood illnesses and operations you have experienced:
Rheumatic Fever
Tonsillectomy
Age_____ Year _____
Age _____Year ______
Appendectomy
Heart Murmur
Age_____ Year _____
Bleeding disorders
Obesity
Blood Clots
Asthma
Date of last Physical___________________________________________________________
(must be done within 6 months of surgery)
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Please list all the physicians whose care you are under:
Name
Location
Telephone
Primary Care Physician: _______________________________________________________
Internist: ___________________________________________________________________
Gynecologist: _______________________________________________________________
Orthopedist: ________________________________________________________________
Psychiatrist: ________________________________________________________________
Psychologist: _______________________________________________________________
Therapist: __________________________________________________________________
Other: _____________________________________________________________________
May we contact your Doctor’s office? _______
For female patients only:
Number of pregnancies: ______________________ Age of first period _________________
Number of live births: ________________________Date of last period _________________
Miscarriages/abortions: ______________________
Obstetric complications: _______________________________________________________
FAMILY HISTORY
Age
Relationship
Health (good,
fair, poor)
If deceased, cause
Age
deceased
Father
Mother
Brothers
Sisters
Spouse
Sons
Daughters
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Do you know of any blood relative that currently has or has had: (list relationship?)
Stroke: ____________________________________________________________________
Cancer: ___________________________________________________________________
High blood pressure: _________________________________________________________
Tuberculosis: _______________________________________________________________
Diabetes: ___________________________________________________________________
Bleeding tendency: ___________________________________________________________
Heart Attack: ________________________________________________________________
PERSONAL HABITS
Are you a smoker?
Yes
No
if yes, when did you quit? _________________________
How many years did you smoke?
Cigarettes _________Pipe ________Cigar ___________
Do you drink coffee? Yes
No
If yes, how much? ______________________________
Do you drink alcohol? Yes
No
If yes, how much? ______________________________
SYSTEM REVIEW
Circle all symptoms which you have now or have had. Write in any additional problems.
Head, Eye, Ear, Nose, & Throat:
Stuffy nose, runny nose, hay fever, sinus trouble, earache, headache, blurry vision, double
vision, halos around light, loss of night vision, buzzing in ears, ringing in ears, discharge
from ear, loss of hearing, dizziness, vertigo, loss of balance, sore throat, lump in throat,
trouble swallowing, pain with swallowing, hoarseness.
Respiratory:
Cough, wheezing, shortness of breath at night, use two pillows, blood in sputum, out of breath
with exertion, wake up at night short of breath; wake up at night coughing or choking, asthma,
emphysema, bronchitis.
Cardiovascular:
Palpitation, pounding of heart, skipping of heart beat, pains in chest, pains in neck, pains, in
arms, squeezing of chest, heart attack, heart murmur, abnormal electrocardiogram, irregular
heartbeat, high blood pressure, pain in legs, cold feet, blue toes, blue fingers, loss of pulses.
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Genitourinary:
Pain with urination, trouble starting urine, trouble stopping urine, small urine stream, blood in
Urine, kidney stone, bladder stones, kidney failure, nephritis, urinary tract infections, frequent
urination, getting up at night to urinate, leakage of urine with coughs or sneeze.
Men:
Discharge from penis, loss of erection, painful erection.
Women:
Vaginal discharge, vaginal bleeding, pain with intercourse, irregular periods.
Endocrine (Glandular):
Low thyroid, hyperthyroid, goiter, Grave’s disease, thyroid nodules, x-ray to thyroid, diabetes,
adrenal gland tumor, frequent flushing, frequent heavy sweating.
Musculoskeletal:
Pain in joints, swelling of joints, redness of skin over joints, warm joints, fluid in joints, arthritis.
Neurological:
Dizziness, vertigo, falling to the side, falling at night, numbness, tingling, pins and needles
feeling, weakness of any muscles, twitching of muscles, weakness of grip, shakiness, tremor,
fainting, convulsions, fits, loss of consciousness.
Psychological:
Nervousness, anxiety, depression, thoughts of suicide, suicide attempts, hospitalizations for
emotional problems, psychiatric treatment, psychological counseling.
Other Problems:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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