Download ucsf bariatric surgery center new patient medical history questionnaire

Bariatric Surgery Center
UCSF Medical Center
400 Parnassus Avenue, Room A655
UCSF BARIATRIC SURGERY CENTER
NEW PATIENT MEDICAL HISTORY QUESTIONNAIRE
Please complete this form to provide information regarding your medical condition. Feel free to ask your
primary care physician for assistance. All information will be kept confidential. Please return the completed
questionnaire with the following:
 Formal letter from your primary care physician, including a 6 month summary of diet and weight history,
a list of co-morbid conditions you have in addition to obesity, and why you are being referred for
bariatric surgery.
 Current insurance authorization for an initial surgical consultation.
 Photocopy of the front and back of your insurance card.
We strive to be detail-oriented and thorough. Your answers here will become part of the UCSF medical record
and will be confidential.
Name: _______________________________
Insurance: _____________________________
Date of Birth: __________________________
Subscriber No: _________________________
Home phone: _________________________
Group ________________________________
Other phone: __________________________
Address: _____________________________
Insurance: _____________________________
_____________________________________
Subscriber No: _________________________
City / State / Zip: _______________________
Group _______________________________
Email address: _________________________
Social Security No: ______________________
Primary language: ______________________
How did you find UCSF Bariatric Surgery?
What is your current weight?_______________
[ ] referred by a friend / relative
[ ] referred by a physician or other provider
[ ] referred by my insurance
[ ] referred by a UCSF bariatric patient
[ ] website: ______________________
[ ] found you on TV, radio, or magazine
What is your current height?_______________
Names of the doctors who referred you, your primary care doctor and any other doctor from whom you are
receiving__________________________
care?
Name:
Date of Birth: _____________________
FOR OFFICE USE:
Doctor who referred you: ___________________________________ City: ___________________
Ideal Body Weight:
__________________________
WEIGHT
HISTORY
Primary care
doctor: ______________________________________ City: ___________________
ADULT NEW PATIENT QUESTIONNAIRE PAGE 1 OF 8
Additional doctor: ________________________________________ City: ___________________
Bariatric Surgery Center
UCSF Medical Center
400 Parnassus Avenue, Room A655
What is your goal weight? ______________
When did your obesity begin? (circle one):
childhood
adolescence
early adulthood
What diet / weight loss programs have you tried in the past? (circle all that apply)
Weight Watchers
Jenny Craig
Curves
South Beach Diet
The Zone
Rosemary Conley
Other:
Slim-Fast
Nutrisystem
Glycemic Impact Diet
Denise Austin Diet
diettogo
Life Diet
What was the most weight you ever lost on a diet? ________________________
Have you ever used diet pills? If so, which ones? _________________________
Circle YES or NO for each question
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Do you live alone?
Do you have difficulty shopping or carrying home a 10 pound bag?
Do you have difficulty dressing yourself?
Are you receiving any special help at home?
Have you had 3 or more falls in the past year?
ADULT NEW PATIENT QUESTIONNAIRE PAGE 2 OF 8
adulthood
Bariatric Surgery Center
UCSF Medical Center
400 Parnassus Avenue, Room A655
ALLERGIC REACTIONS TO MEDICATIONS
Have you ever had a reaction to any of the following:
YES NO Latex
YES NO Iodine
YES NO Intravenous contrast agent (used in CT scans)
Are you allergic to any medications? If so, list the medication and the reaction that you had:
MEDICATION
Example:
Aspirin
REACTION (circle all that apply)
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
anaphylaxis/shock
rash
itching
nausea/vomiting
short-of-breath
other:
ADULT NEW PATIENT QUESTIONNAIRE PAGE 3 OF 8
Bariatric Surgery Center
UCSF Medical Center
400 Parnassus Avenue, Room A655
PAST MEDICAL HISTORY
Please circle any illnesses you have now or in the past.
GENERAL MEDICAL PROBLEMS
Seasonal allergies (hay fever)
Anemia
Anxiety
Arthritis
Bleeding disorders
Blood disorder
Blood transfusion in the past
Cancer (list types)
Clotting disorder
Chronic bronchitis or emphysema
Glaucoma
Heart disease
HIV/AIDS
Intestinal disease
Kidney disease
Liver disease
Myocardial infarction
Nerve / muscle disease
Osteoporosis
Seizures
Sinus disorder
Skin disease
Stroke
Substance abuse
Thyroid disease
Ulcers
OTHER:
OBESITY-RELATED PROBLEMS
Hypertension (high blood pressure)
Congestive heart failure
Coronary artery disease (heart attacks)
Varicose veins / venous stasis disease
Diabetes (high blood sugar)
Dyslipidemia (high cholesterol)
Polycystic Ovarian Syndrome
Gout
Osteoarthritis (painful joints)
Intertrigo (yeast infections in skin folds)
Obstructive Sleep Apnea (stop breathing at night)
Pickwickian Syndrome (low blood oxygen)
Asthma
Gastroesophageal reflux (Heartburn)
Fatty liver disease
Urinary Stress Incontinence (leak urine with cough)
Intracranial hypertension
Migraines
Depression
Blood clots in legs or lungs
Gallstones or gallbladder disease
Have you ever been hospitalized? If yes, list the date(s) and reasons.
ADULT NEW PATIENT QUESTIONNAIRE PAGE 4 OF 8
Bariatric Surgery Center
UCSF Medical Center
400 Parnassus Avenue, Room A655
PAST SURGICAL HISTORY
Please circle any operations you have had.
Year performed
Appendectomy
Brain surgery
Breast surgery
Coronary artery bypass surgery
Cholecystectomy (gallbladder removal)
Colon surgery
Cosmetic surgery
Cesarian section
Eye surgery
Fracture surgery
Hernia repair
Hysterectomy (uterus removal)
Joint replacement
Prostate surgery
Small intestine surgery
Spine surgery
Tubal ligation
Valve replacement
Vasectomy
OTHER:
ADULT NEW PATIENT QUESTIONNAIRE PAGE 5 OF 8
Bariatric Surgery Center
UCSF Medical Center
400 Parnassus Avenue, Room A655
Mother
Father
Sister
Brother
Son
Mat Aunt
Mat Uncle
Pat Aunt
Pat Uncle
Mat GM
Mat GF
Pat GM
Pat GF
Cousin
SOCIAL HISTORY
Do you drink alcohol? YES NO
If yes, what is your average number of:
glasses of wine per week
cans of beer per week
shots of liquor per week
Do you use drugs recreationally now?
If yes, circle the drugs you use:
amphetamines
“crack” cocaine
heroin
marijuana
morphine
psilocybin
YES
amyl nitrate
cocaine
hydrocodone
MDMA
nitrous oxide
solvent inhalants
NO
anabolic steroid
codeine
hydromorphone
methamphetamine
opium
IV drugs
barbituates
fentanyl
ketamine
methaqualone
oxycontin
other:
benzodiazepines
GHB
LSD
methylphenidate
PCP
other:
Are you a (circle one): current smoker
former smoker
never smoker
passive smoker
How many packs of day do you smoke, on average? _________________________
How many years have you smoked?
______________________________________
ADULT NEW PATIENT QUESTIONNAIRE PAGE 6 OF 8
Vision loss
Tuberculosis
Thyroid disease
Stroke
Osteoporosis
Mental illness
Liver disease
Kidney disease
Hypertension
Hyperlipidemia
Heart disease
Early death
Drug abuse
Diabetes
Depression
Colon Cancer
Cancer
Breast cancer
Bleeding disorder
Asthma
Arthiritis
Alzeihmeris
Lou Gehrig’s
Alcoholism
FAMILY HISTORY
Mark an “X” in the box if any of relative of yours had one of these diseases:
Bariatric Surgery Center
UCSF Medical Center
400 Parnassus Avenue, Room A655
REVIEW OF SYSTEMS
Have you experienced any of the following symptoms in the past 3 months?
GENERAL
SKIN
HEAD
EYES
CARDIOVASC
LUNGS
ABDOMEN
URINARY
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Symptom
fevers
chills
weight loss
malaise or fatigue
sweating
weakness
rash
itching
headaches
hearing loss
tinnitus
ear pain
ear discharge
nosebleeds
congestion
stridor (groan when you breathe)
sore throat
blurred vision
double vision
irritation with lights (photophobia)
eye pain
eye discharge
eye redness
chest pain
palpitations (fluttering in the chest)
orthopnea (difficulty breathing while flat in bed)
claudication (pain in legs with exercise)
leg / ankle swelling
difficulty breathing during sleep
cough
hemoptysis (coughing up blood)
sputum production (coughing up phlegm)
shortness of breath
wheezing
heartburn
nausea
vomiting
abdominal pain
diarrhea
constipation
bright red blood in stool
melena (dark, tar like stools from old blood)
dysuria (burning when you pee)
urgency (need to pee quickly, can’t barely hold it)
frequency (need to pee often)
hematuria (blood in the urine)
flank pain
ADULT NEW PATIENT QUESTIONNAIRE PAGE 7 OF 8
Comments
Bariatric Surgery Center
UCSF Medical Center
400 Parnassus Avenue, Room A655
MUSCLES
BLOOD
NEURO
PSYCHIATRIC
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
myalgias (crampy muscle pain)
neck pain
back pain
joint pain
falls
easy bruising or easy bleeding
seasonal allergies
polydipsia (always thirsty)
dizziness
tingling
tremor
sensory change
speech change
focal weakness
seizures
loss of consciousness
depression
suicidal ideas
substance abuse
hallucinations
nervous / anxious
insomnia
memory loss
ADULT NEW PATIENT QUESTIONNAIRE PAGE 8 OF 8