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George E. Reiss, MD., F.A.C.S. │ Richard B. Wilson, M.D., F.A.C.S. │ Robin D. Haussmann, P.A.-C Bariatric Surgery History and Profile Patient Name: ___________________________________________________ Date of Birth: ___________________________ Physicians Primary Care Physician: ______________________________________ Telephone #: _________________ Cardiologist: ________________________________________ Telephone #: _________________ Psychologist: ________________________________________ Telephone #: _________________ Psychiatrist: ________________________________________ Telephone #: _________________ Pulmonologist: ________________________________________ Telephone #: _________________ Endocrinologist: ________________________________________ Telephone #: _________________ Orthopedic Surgeon: ________________________________________ Telephone #: _________________ Other: Telephone #: _________________ ________________________________________ Weight History Height: Feet: _________ Inches: _________ Weight: ______________ lbs. Age of Obesity Onset: 0-2 years old 2-12 years old 12-18 years old Young Adult Middle Age How many years have you been at your present weight? ________________ Greatest single weight loss: ________________ Weight loss sustained for: ________________ Were there any particular events that lead to significant weight gain? __________ Loss of a loved one Trauma-accident Illness Pregnancy Loss of employment George E. Reiss, MD., F.A.C.S. │ Richard B. Wilson, M.D., F.A.C.S. │ Robin D. Haussmann, P.A.-C Diet History Name of Diet Program Acupuncture American Heart Association Atkins Cabbage Diet Calorie Counting Carefast Dexatrim Diet Center Duke University Programs Fastin Grapefruit Diet Herbal Diets Hypnosis In-patent Psychiatric Programs Ionamin Jenny Craig Low Fat Medifast Nutri-Systems O.A. Optifast Phenetamine/Fenfluramine Pritikin Radar Institute Redux Rice Richard Simmons Scarsdale Slim Fast Structure House Teeth Wiring TOPS Weight Watchers Xenical Other Started Ended Pounds Lost Pounds Regained Number of Months George E. Reiss, MD., F.A.C.S. │ Richard B. Wilson, M.D., F.A.C.S. │ Robin D. Haussmann, P.A.-C Diabetes If you have been diagnosed with or treated for diabetes, please complete the following section. Juvenile Onset: Yes No Year Diagnosed ______________ Adult Onset: Yes No Year Diagnosed ______________ Current Form of Control Diet Control Only Yes No As of Year ______________ Oral Hypoglycemics Yes No As of Year ______________ Insulin Yes No As of Year ______________ Do you have glycosylated hemoglobin - HbA1c levels tested? Number of units per day _____________ Yes No If yes, do you know what your level is ? _________ Sleep Apnea Please complete the following even if you have not been diagnosed with sleep apnea. Do you use a C-Pap: Yes No Do you use a Bi-Pap: Yes No Please mark which symptoms apply YES Snorting or gasping Loud snoring Breathing stops, choke or struggle for breath Frequent awakenings Tossing, turning or thrashing Difficulty falling asleep Morning headaches Night sweats More than three pillows used under head Falling asleep when at work or school Falling asleep when driving Excessive sleepiness during the day Awakening feeling paralyzed, unable to move for short periods Do you feel more comfortable sleeping in an upright position How well rested do you feel after a full night’s sleep? Not at all NO Somewhat GERD Please complete the following even if you have not been diagnosed with GERD How often do you have reflux during the day? Many times per day Everyday Most Days Most Weeks Occasionally Do you suffer from heartburn/indigestion during the night? If so, how often? Many times per day Everyday Most Days Most Weeks Occasionally Does food or fluid reflux in the mouth? Do you vomit with reflux? Yes No Yes No Well Rested George E. Reiss, MD., F.A.C.S. │ Richard B. Wilson, M.D., F.A.C.S. │ Robin D. Haussmann, P.A.-C Treatments you may use for reflux, heartburn or indigestion, either prescribed or over-the-counter. Check all those that apply. Zantac Tagamet Pepcid Prevacid Nexium Prilosec Surgery Other: ________ Please list any current medical conditions or concerns no covered above: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Endoscopy: Date __________________ Name of GI Physician: _____________________________________________ Findings: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Social Profile Do you drink coffee? Yes No How may cups per day _____ Do you smoke cigarettes? Yes No If yes, how long __________ Do you smoke cigars? Yes No How many per day _________ How long ago did you stop smoking? Years _____ Months ______ Do you drink alcohol? Yes No If yes, how often? Everyday Most Days Most Weeks Occasionally If yes, when drinking do you tend to binge to excess? Yes No Do you have a history of drug or alcohol addiction? Yes No If yes, how long have you been alcohol or drug free? Years _____ Rarely Months ______ What treatment did you receive, check all that apply: Residential treatment Counseling Support groups such as AA Family Structure Do you have any children: Yes No How many children/grandchildren in each of the following age groups do you have living with you? Include nieces, nephews or other dependants. 0-2 years old _____ 13-18 years old _____ 3-8 years old _____ 19-25 years old _____ Do you have a support person or friend? Do they live with you? 9-12 years old _____ Over 25 years old _____ Yes No Yes No Current Employment Are you currently employed? Yes No Occupation: ______________________________________ Employer: ____________________________________________ Do you enjoy your work? Yes No If you are unemployed, how long? _____________________ What is the reason? Physically unable to work Emotionally unable to work Lack of available jobs in field Lack of skills Appearance inappropriate for position sought Are you currently disabled or on disability? Yes No If so, how long? ___________________________ George E. Reiss, MD., F.A.C.S. │ Richard B. Wilson, M.D., F.A.C.S. │ Robin D. Haussmann, P.A.-C Education 8TH grade or less Some high school High school graduate College graduate Some college Any post graduate work Surgical History Type of Surgery Adenoidectomy Angioplasty Ankle Surgery Appendectomy Back Surgery Breast Augmentation Breast Reduction Carpal Tunnel Surgery Cholecystectomy, Laparoscopic Cholecystectomy, Open Coronary Bypass D&C (dilation and curettage) Gastric Bypass Hemorrhoidectomy Hernia Repair Hysterectomy Knee Surgery Lap Band Lasik Liposuction Lumbar Laminectomy Mastectomy Oral Surgery Ovarian Cystectomy Panniculectomy Pilonidal Cystectomy Prostate Surgery Tonsillectomy Tubal Ligation VBG (Vertical banded gastroplasty) Wisdom Teeth Check surgeries you have had Year of surgery George E. Reiss, MD., F.A.C.S. │ Richard B. Wilson, M.D., F.A.C.S. │ Robin D. Haussmann, P.A.-C Do you have any problems with anesthesia? Yes No If yes, please describe: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Have you had a previous blood transfusion: Yes No If so, list date(s)? _________________________ Medications List all the medications you are currently taking. Use the information from the prescription label on pill bottle. Include all herbal supplements and multivitamins. Drug Name and Dosage Reason for Medication Prescribing Physician Allergies Drug Name If Allergic, Please Check Box No known drug allergies Aspirin Codeine Demerol Erythromycin Iodine Keflex Morphine Penicillin Sulfa Tetracycline Other Other Indicate Reaction George E. Reiss, MD., F.A.C.S. │ Richard B. Wilson, M.D., F.A.C.S. │ Robin D. Haussmann, P.A.-C Non-Drug Allergies If Allergic, Please Check Box Indicate Reaction Tape Food Allergies Latex Products Does your occupation involve exposure to NRL (Natural Rubber Latex)? Family Medical History Relationship Living Deceased Age Age Circle Cause of Death Circle Medical History Father Cancer Accident Age Related Diabetes Heart Disease Stroke Heart Attack Other: _____________________ Obesity Heart Disease Hypertension Diabetes Cancer: Breast Prostate Colon Thyroid Skin Blood Other: _____________________ Mother Cancer Accident Age Related Diabetes Heart Disease Stroke Heart Attack Other: _____________________ Obesity Heart Disease Hypertension Diabetes Cancer: Breast Prostate Colon Thyroid Skin Blood Other: _____________________ Sister Cancer Accident Age Related Diabetes Heart Disease Stroke Heart Attack Other: _____________________ Obesity Heart Disease Hypertension Diabetes Cancer: Breast Prostate Colon Thyroid Skin Blood Other: _____________________ Brother Cancer Accident Age Related Diabetes Heart Disease Stroke Heart Attack Other: _____________________ Obesity Heart Disease Hypertension Diabetes Cancer: Breast Prostate Colon Thyroid Skin Blood Other: _____________________ Spouse: History of Obesity? Yes No Children: History of Obesity? Yes No
