BMI of Texas 9910 Huebner Rd, Suite #250 San Antonio TX 78240
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BMI of Texas 9910 Huebner Rd, Suite #250 San Antonio TX 78240 Phone (210)615-8500 Fax (210)615-8501 New Bariatric Surgery Patient Intake Questionnaire In order to minimize your wait time and maximize your experience at BMI of Texas, please take a moment to complete this questionnaire. We realize this is a lengthy form but assure you it is all important information and will be kept confidential.
Please Print First Name: ________________________Last Name: _______________________DOB:_________________
Preferred Surgeon (circle one):
Desired Procedure:
Michael Seger, MD
Terive Duperier, MD
First Choice
Richard Englehardt, MD
Second Choice
Roux-En-Y Gastric Bypass
Roux-En-Y Gastric Bypass
Adjustable Gastric Band
Adjustable Gastric Band
Gastric Sleeve
Gastric Sleeve
Revision
Revision
Undecided
Undecided
Chief Complaints: Morbid Obesity
Fatty Liver (alcoholic)
Osteoarthritis - Hip
Asthma
Fatty Liver (non-alcoholic)
Osteoarthritis - Knee
Decreased Quality of Life Gastroesophageal Reflux Disease
Pulmonary Disease
Deep Venous Thrombosis Heart Disease w/o CABG
Sleep Apnea w/ CPAP
Depression
Heart Disease w/ CABG
Sleep Apnea w/o CPAP
Diabetes Type I
Inability to Lose or Maintain Weight
Urinary Stress Incontinence
Diabetes Type II
Joint Pain
Venous Stasis
Dyslipidemia
Low Back Pain
Edema
Menstrual Abnormalities
CONTINUE TO NEXT PAGE Staff Use Only: Advocate: ______________________________________ Surgeon: ____________________________ Appointment Date: ___________________________________ Time: __________________________
Adipose Relate Comorbities Diabetes
Date of onset: ________________
Taking Rx? ________________
Hypertension
Date of onset: ________________
Taking Rx? ________________
Sleep Apnea
Date of onset: ________________
Taking Rx? ________________
CAD
Date of onset: ________________
Taking Rx? ________________
PVD
Date of onset: ________________
Taking Rx? ________________
Venous Disease
Date of onset: ________________
Taking Rx? ________________
Hyperlipidemia
Date of onset: ________________
Taking Rx? ________________
COPD
Date of onset: ________________
Taking Rx? ________________
Renal Insufficiency
Date of onset: ________________
Taking Rx? ________________
Arthritis
Date of onset: ________________
Taking Rx? ________________
GERD
Date of onset: ________________
Taking Rx? ________________
Weight History How many years have you been at your current weight? ______________ How many years have you been obese? ___________ How many years have you been more than 35 pounds overweight? __________ How many years have you been more than 100lbs overweight? _________ At what age did you start to diet? _______________ What is your maximum weight you’ve reached? ________________ What was your most significant amount of weight loss? _____________ How long was this loss sustained? ________________________________________________________ What was your method of weight loss? ____________________________________________________ Do you consider yourself to be: (circle all that apply) Volume Eater -- Sweet Eater -- Snacker/Grazer -- Emotional Eater -- Binge Eater
Please indicate which unsupervised diets you have tried in the past: Atkins
Health Spa
Pritkin
AYDS
Herbal Life
Richard Simmons
Binging/Purging
High Protein
Stillman Diet
Body for Life/Bill Phillips
Home Gym Equipment
Slim Fast
Calorie Counting
Hypnosis
South Beach Diet
Gloria Marshall
Low Carbohydrates
Sugar Busters
Gym Membership
Mayo Clinic Diet
Zone
Scarsdale Diet
Other ___________
Please indicate which supervised diets you have tried in the past: Acupuncture
Medifast
Physician Wt. Loss Center
Diet Center
Metrical
Psychological Counseling
Diet Pills from MD
National Weight Loss
Supervised Calorie Counting
Diet Shots from MD
Nutri-System
T.O.P.S
Exercise Counseling
Nutritional Counseling
Weigh of Life
Health Management Resources
Optifast
Weight Watchers
New Direction
Overeaters Anonymous
Other ___________________
Jenny Craig
Personal Trainer
Please indicate which weight loss medications you have tried in the past: Accutrim
Fenfluramine
Phentermine/Fastin/Adipex
Amphetamines
Herbal Remedies
Phentrol
Anorex
Ionamin
Plegine
Benzphetamine
Laxatives
Pondimin
Dexatrim
Mazanor
Redux
Didrex
Meridia
Sanorex
Diuretics
Metabolife
Tepanol
Fastin
Obalan
Tenuate
Fen-Phen,
Orlistat/Xenical/Alli
Topomax
Phendiet
Wehless
# of months used ______
Other ___________
Please indicate which methods of exercise you have previously tried to lose weight. Sedentary
Weight Training
Walking or Running
Group Classes
Stationary Cycle
Jogging
Treadmill
Tennis/Racquet Sports
Swimming
Team Sports
Other: __________________
Please indicate if you have utilized any of the following to assist with your weight loss attempts: Hospitalization
Psychological Therapy
Hypnosis
Residential Programs
Physical Therapy
Support Groups
Other: __________________
Medical History Please carefully review the list of medical conditions/problems listed below and check any that apply to you: GERD
Osteoarthritis – Shoulder
Angina
Helicobacter Pylori
Osteoarthritis – Wrist
Arrhythmia
Hemmorrhoids
Osteopenia
Cardiac Palpitations
Hiatel Hernia
Osteoporosis
Cardiomyopathy
Rectal Bleeding
Pain – Ankles/feet
Congestive Heart Failure
Ulcer – Duodenal
Pain – Back
DVT (blood clot)
Ulcer – Esophageal
Pain – Elbows
Dyspnea with Exertion
Ulcer – Gastric
Pain – Hands
Cardiac
Autoimmune
Heart Disease w/o CABG
Pain – Hips
Heart Disease w/ CABG
Crohn’s Disease
Pain – Knees
Heart Murmur
Lupus
Pain – Neck
Hypercholesterolemia
Metabolic Syndrome
Pain – Shoulder
Mitral Valve Regurgitation
Psoriatic Arthritis
Pain – Wrist
Myocardial Infarction
Rheumatoid Arthritis
Scoliosis
Peripheral Edema
Sarcoidosis
Peripheral Vascular Disease
Ulcerative Colitis
Varicose Veins Venous Insufficiency
Cancer
Gynecological
Psychosocial Alcoholic Anxiety
Amenorrhea
Bipolar Disorder
Dysfunctional Uterine
Depression
Neurological
Breast Cancer
Bleeding
Lymphedema
Dysmenorrhea
CVA
Skin Cancer
Gestational Diabetes
Insomnia
Cancer
Infertility
Intracranial Hypertension
Menstrual Irregularity
Migraine Headaches
Polycystic Ovary Disease
M ultiple Sclerosis
Infectious Disease Hepatitis B
Musculoskeletal
Hepatitis C
Narcolepsy
HIV/AIDS
Carpel Tunnel Syndrome
Neuralgia Paresthetica
MRSA History
Chronic Back Pain
Pseudotumor Cerebri
Lyme Disease
Degenerative Disk Disease
Seizure Disorder
Tuberculosis Exposure
DJD
Sleeping Disorder
Gastrointestinal
Urinary
Fibromyalgia
Barrett’s Esophagus
Joint Pain
BPH
Cholelithaisis/Cholecystitis
Osteoarthritis – Ankles/Feet
Nocturia
Colitis
Osteoarthritis – Elbows
Frequent UTI
Elevated Liver Enzymes
Osteoarthritis – Hands
Prosatitis
Fatty Liver (alcoholic)
Osteoarthritis – Hips
Renal Lithiasis
Fatty Liver (non-alcoholic)
Osteoarthritis – Knees
Stress Urinary Incontinence
Gastroparesis
Osteoarthritis – Neck/back
Urinary Incontinence
Abdominal
Gout
Hernia
Hypothyroidism
Hernia – Incisional
Morbid Obesity
Hernia – Inguinal
Pancreatitis
Hernia – Umbilical
Pituitary Tumor
Hematological Abnormal Bleeding Anemia Blood Clotting Disorder
Thyroid Disease
Eyes
Coagulopathy
Pulmonary
Glaucoma
Skin Cellulitis Interiginous Dermatitis Psorasis
Endocrine Diabetes Type I
Factor V Leiden
Asthma
Hypercoaguable State
Bronchitis
Thrombocytopenia
Pneumonia
Thrombophlebitis
COPD
Transfusion History
Pulmonary Embolus
Antibiotics before dental work
Seasonal Allergies
Other: ___________________
Sleep Apnea, no CPAP
Diabetes Type II Gluclose Intolerance
Sleep Apnea CPAP
No medical History
Dependent
Surgical History: Please list non-bariatric surgeries (surgeries not related to weight loss) you have had or indicate if you have not had any.
No prior non-bariatric surgeries
Example: Open Hysterectomy w/ ovaries removed, 1/25/99, no complications Procedure/Surgery: specify laparoscopic/Open
Date:
Please list previous bariatric (weight loss) surgeries:
Complications:
No prior bariatric surgeries
Procedure/Surgery: (laparoscopic/Open)
Date:
Original Weight:
Lowest Weight
Complications:
Medications: Please list below any and all medications/vitamins you are currently taking. Example: Lipitor 10mg one tablet daily at bedtime 1.____________________________________________________________________________________ 2.____________________________________________________________________________________ 3.____________________________________________________________________________________ 4.____________________________________________________________________________________ 5.____________________________________________________________________________________ 6.____________________________________________________________________________________ 7.____________________________________________________________________________________ 8.____________________________________________________________________________________ 9.____________________________________________________________________________________ 10. ____________________________________________________________________________________ Not currently taking any medications Allergies: Do you have allergies to any of the following:
Medications, if so, please list medication and reaction: __________________ _______________________________________________________________ _______________________________________________________________
Latex
Iodine, when: ____________________________________________________
IV Contrast, when: ________________________________________________
Adhesives, type: _________________________________________________
No Known Allergies
Disability: Are you currently considered to be disabled by the U.S. Social Security Administration?
No
Yes
If yes, for what reason are you disabled?
Year of disability: ________________
Motor vehicle accident
Disability due to recent disabling illness
Work related disability
Disability due to chronic medical condition: (describe)__________________________
Do you require assistive device?
Yes
If yes, indicate which type? Cane
Crutches
No Walker Braces
Do you utilize a wheelchair or motorized scooter?
Yes
No
If yes, how long have you required this assistance? __________________________________
Family History: (Please include only parents, grandparents, and siblings) Illness/Medical Condition
Family Member
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
Social History: Do you currently smoke?
No
Rarely
Occasionally
Frequently
If yes, How many packs per day? _______________ For past smokers How many years ago did you quit smoking? ____________ How many years did you smoke? ______________ How many packs a day did you smoke? _________________
Do you drink alcohol?
No
Rarely
Occasionally
Frequently
If yes, how many times/week? __________________________
Do you currently use illicit/street drugs? No
Rarely
Occasionally
Frequently
If yes, what type did/do you use and how often? _________________________________________
*Note to patient: We apologize for the length of this form but we feel that all of this information is very important to enable our office and staff to provide you with excellent care.
Review of Systems Neurologic Ataxia Dizziness Headaches Insomnia Paralysis Parethesia Sensory Loss Seizures Sleepiness Stroke Syncope Weakness Psychosocial Alcohol Use Confirmed Mental Health Disorder Depression Enrolled in Chemical Dependency Inpatient Psychiatric Care Mental/Emotional Abuse Physical Abuse Psychosocial Impairment Seen Psychiatrist or Counselor Sexual Abuse Substance Abuse Suicide Attempt Tobacco Use Head and Neck Epistaxis Hearing Problems Hoarseness Lymphadenopathy Constitutional Appetite Change Chills Fatigue Fevers Hair Loss Night Sweats Weight Change Cardiovasuclar Angina Congestive Heart Failure
Deep Venous Thrombosis Hypertension Irregular/Skipped Heart Beat Ischemic Heart Disease Lower Extremity Edema Pacemaker Peripheral Vascular Disease Rapid Heart Rate Rheumatic Fever / Value Damage/ MVP Varicose Veins
Respiratory Obstructive Sleep Apnea Pulmonary Hypertension Asthma Obesity Hypoventilation Syndrome Chronic Cough Shortness of Breath at Rest Emphysema/COPD Bronchitis Pneumonia Endocrine/Metabolic Abnormal Facial Hair Growth Diabetes Type I Diabetes Type II Dyslipidemia Elevated Calcium Level Endocrine Gland Tumor Excessive Thirst Excessive Urination Goiter Gout Hyperthyroid (overactive) Hypothyroid (low thyroid) Low Blood Sugar Parathyroid Problems Hematological Anemia Anemia (Fe deficiency) Anemia – Pernicious (B12 deficiency) Anticoagulant Use Coagulopathy Easy Bleeding
Gastrointestinal Abdominal Pain Barrett’s Esophagus Black Tarry Stools Blood in Stool Change in Bowel Habits Colitis Colon Polyps Constipation Crohn’s Disease Diarrhea Difficulty Swallowing Gallstones GERD Heartburn Hemorrhoids Hiatel Hernia Incisional Hernia Irritable Bowel Liver Disease Nausea / Vomitting Pancreatic Musculoskeletal Autoimmune Disease Back Pain Broken Bones Carpel Tunnel Syndrome Fibromyalgia Lupus Musculoskeletal Disease Plantar Fasciitis Rheumatoid Arthritis Sciatica Scleroderma Ankle Pain Ball of foot/toe pain Foot Pain Hip Pain Knee Pain Muscle Pain Neck Pain Shoulder Pain Wrist Pain Gynecological Polycystic Ovarian Syndrome Menstrual Irregularities
Breast Cancer Breast Masses Fibrocystic Disease Infertility Mastodynia (Breast Pain) Nipple Discharge Post Menopausal Uterine/Ovarian Cancer Last Pap ____________________________ Last MMG __________________________ Are you pregnant? ____________________ Are you planning more children? ________ How many pregnancies? _______________ How many children? __________________ How many miscarriages/abortions? ______
Urinary Dysuria Hematuria Hesitancy Kidney Failure/Renal Insuff Kidney Stones Leaking Urine when Sneezing Nocturia Previous PSA Test (male) Prostate Problems Trouble Starting Urination Urinary Frequency Urinary Incontinence Urinary Urgency Dermatological Hair/Nail Changes History of MRSA Intertrigo Lesions Masses Non-Healing Wounds Rashes
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