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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