Microsoft word - np wls intake form 2014.doc

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): Michael Seger, MD Desired Procedure: First Choice
Chief Complaints:
CONTINUE TO NEXT PAGE
Staff Use Only:
Advocate: ______________________________________ Surgeon: ____________________________ Appointment Date: ___________________________________ Time: __________________________ Adipose Relate Comorbities
Date of onset: ________________ Taking Rx? ________________ Date of onset: ________________ Taking Rx? ________________ Date of onset: ________________ Taking Rx? ________________ Date of onset: ________________ Taking Rx? ________________ Date of onset: ________________ Taking Rx? ________________ Date of onset: ________________ Taking Rx? ________________ Date of onset: ________________ Taking Rx? ________________ Date of onset: ________________ Taking Rx? ________________ Renal Insufficiency Date of onset: ________________ Taking Rx? ________________ Date of onset: ________________ Taking Rx? ________________ 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:
Please indicate which supervised diets you have tried in the past:
Please indicate which weight loss medications you have tried in the past:
Please indicate which methods of exercise you have previously tried to lose weight.

Please indicate if you have utilized any of the following to assist with your weight loss attempts:

Medical History
Please carefully review the list of medical conditions/problems listed below and check any that apply Autoimmune
Psychosocial
Gynecological
Neurological
Infectious Disease
Musculoskeletal
Gastrointestinal
Abdominal
Hematological
Pulmonary
Endocrine
No medical History
Surgical History:
Please list non-bariatric surgeries (surgeries not related to weight loss) you have had or indicate if you have not had
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:
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. ____________________________________________________________________________________ Allergies: Do you have allergies to any of the following:
Medications, if so, please list medication and reaction: __________________ _______________________________________________________________ _______________________________________________________________ Iodine, when: ____________________________________________________ IV Contrast, when: ________________________________________________ Adhesives, type: _________________________________________________ Disability:
Are you currently considered to be disabled by the U.S. Social Security Administration? If yes, for what reason are you disabled? Year of disability: ________________ Disability due to recent disabling illness Disability due to chronic medical condition: (describe)__________________________ Do you utilize a wheelchair or motorized scooter? If yes, how long have you required this assistance? __________________________________ Family History: (Please include only parents, grandparents, and siblings)
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
Social History:
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? _________________ If yes, how many times/week? __________________________ Do you currently use illicit/street drugs? No Rarely 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
Respiratory
Psychosocial
Endocrine/Metabolic
Head and Neck
Constitutional
Hematological
Cardiovasuclar
Gastrointestinal
Are you planning more children? ________ Musculoskeletal
Dermatological
Gynecological

Source: http://www.bmioftexas.com/ckfinder/userfiles/files/NP%20WLS%20Intake%20form%202014.pdf