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Denverobesitysurgery.com

WEIGHT LOSS SURGERY HEALTH QUESTIONNAIRE

Patient Name: _________________________________________ Date of Birth: ____________

The following information is very important to your health. Please take time to fully and
completely fill out these forms. Important decisions are based on this information.

Weight Loss History:
Please check the appropriate boxes and add notes as needed (please be specific).
My obesity started:  In childhood
Additional notes regarding the onset of obesity: ____________________________________________ _______________________________________________

Medical Problems:
Have you been diagnosed with any of the following?
___ Diabetes
___ Stomach Ulcers ___ Autoimmune Disorder
Number of visits to your physician for medical problems (asthma, hypertension, heart problems,
diabetes, arthritis, respiratory, circulation, etc) related to obesity:
Monthly ________

Medically Supervised Weight Loss Attempts:

Drs who are following,
Length of
Regained
Patient Name: _________________________________________ Date of Birth: ____________

Weight Loss Programs/Diets/Medications
:
PROGRAM
REGAINED
TIMES PROGRAM
MEDICATIONS:
Patient Name: _________________________________________ Date of Birth: ____________
Eating Habits: (please check all that apply)
Do you consider yourself a:
 Grazer
Do you eat for any of the following reasons:  Stress  Boredom  Loneliness  Other: _________________

Physical Exercise:
PROGRAM

TIME SPENT
REGAINED
OF
PROGRAM


Describe the limitation (physical, emotional, employment) morbid obesity imposed on you in your daily
activity: (If additional space is required, please use a separate sheet.)
___________________________________________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
The above is true and correct to the best of my belief.
Patient Signature: _______________________________________

Date: __________________

Physician Signature: ____________________________________

Date: __________________
PATIENT INFORMATION
Please fill out completely
Patient Name: ____________________________________________________________________ __________________ ______ ___________ First
Address: ___________________________________________________________City:________________________ State: _______ Zip: __________
Home phone: _____________________________ Cell phone: _____________________________ Work Phone: ___________________________
Social Security Number: ____________________________ Driver’s License#:__________________ Email: __________________________________
Employer: __________________________________________________________________ Occupation: ___________________________________
Employment Address: ________________________________________________________________ May we contact you at work? (Circle) Yes No

Emergency Contact:
Name: ________________________________________________________ Relationship: _____________________________
Home Phone: __________________________________________________ Work Phone: ______________________________________________
Who referred you to our office?
Name: ________________________________________________________________________________ Phone: ____________________________
Address: ___________________________________________________________City:________________________ State: _______ Zip: __________

Primary Care Physician:

Name: ________________________________________________________________________________ Phone: ____________________________
Address: ___________________________________________________________City:________________________ State: _______ Zip: __________
***In order to avoid error or delay in the processing of your insurance claim, it is essential that the following section be filled out completely***

PRIMARY INSURANCE COMPANY

Insurance Company: _______________________________________ ID #: _________________________ Group #: ___________________________ Patient Name: ____________________________________________ Your relationship to the Policy Holder: Spouse Self Other: ______________
(Complete this section only if Patient Name is different than Policy Holder)

*Policy Holder Name: _______________________________________ *Date of Birth: __________________
Employer Name: __________________________________________ Employer Phone #: ________________________________________________
SECONDARY INSURANCE COMPANY
Insurance Company: _______________________________________ ID #: _________________________ Group #: ___________________________ Patient Name: ____________________________________________ Your relationship to the policy holder: Spouse Self Other: ______________
(Complete this section only if Patient Name is different than Policy Holder)

*Policy Holder Name: _______________________________________ *Date of Birth: __________________
Employer Name: __________________________________________ Employer Phone #: ________________________________________________
It is my responsibility to pay any co-payment, deductible amount, co-insurance or any other balance not paid by my insurance. If it becomes necessary for
my account to be turned over to a collection agency, I understand that collection fees will be added to my balance. I understand I will be responsible to
pay all collections fees, attorney fees and court costs.
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, Medicaid, Private
Insurance and other Health Plans to: Center of Surgical Specialists, PC. This assignment will remain in effect until revoked by me in writing. A
photocopy of the assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid
by said insurance. I hereby authorize said assignee to release all information, including medical history and medical records, to my insurance company.
___________________________________________________________ _____________________________________
PATIENT SIGNATURE
Update: _______________
Patient History Form
DATE: ___________________
Patient Name: __________________________________ Age: ____________ Date Of Birth: ___________________ The following information is very important to your health. Please take time to fully and completely fill out these
forms. Important decisions are based on this information.

ALLERGIES: Are you allergic to any medications (including over-the-counter drugs or iodine, tape or latex)?
_______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________
MEDICAL PROBLEMS:
Please list all medical problems you have.
_______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ MEDICATIONS:
Please list all medications (specify dosage and frequency) you are currently taking, including
aspirin, over-the-counter medications, vitamins and herbal supplements.
_______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ OPERATIONS:
Please list all operations you have had.
_______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________ _______________________________________________ _____________________________________________
SOCIAL HISTORY:
Do you use any type of tobacco product?
If yes, how much per day _______________ Have you EVER used any type of tobacco product? Do you use illicit drugs? Yes No If yes, please list: ______________________________________
For women: Last menstrual period: _______________ Number of Pregnancies: ______ Number of Live Births: _______

Physician Signature: ______________________________________

Date: ___________________________
Patient Name: ________________________________ Date of Birth: ________________
MEDICAL HISTORY:
Have you been diagnosed with and/or are you currently having any of the following symptoms?

Neurologic/HEENT:
Have you had any neurological problems? Yes___ No___ Digestive (Stomach/Bowel):
Have you had any digestive problems Yes___ No___ Musculoskeletal/Skin:
Have you had any muscle/bone problems? Yes___ No___ Genitourinary/GYN:
Endocrine:
Have you had any endocrine problems? Yes___ No___ Respiratory:
Have you had any breathing problems? Yes___ No___ Ever taken birth control pills? When: _________ Constitutional:
Cardiac:
Communicable Diseases:
Have you had any heart problems? Yes___ No___ Psychological (Emotional):
Blood/Immune System:
Other _____________________________________ Physician Signature: _______________________________
Date: _____________________________
Patient Name: __________________________________ Date of Birth: ________________
Cancer:

Have you ever been diagnosed with cancer? Yes___ No___
Type of Cancer:

Other:
Have you had any other medical problems not listed here?
Yes___ No___ Please list below:
____________________________________________________________________________________________
____________________________________________________________________________________________ ____________________________________________________________________________________________
FAMILY HISTORY:
Please check which, if any, of your blood relatives had any of the following conditions:
Condition
Siblings/
Other Relatives
No Family
Don’t Know
Children


Physician Signature: ______________________________________

Date: ______________________

***No changes to history***
Physician Signature: ______________________________________
Date: ______________________
Our commitment is to provide the very best care to our patients while recognizing the need to limit services to only those that are
necessary for each patient. To meet this commitment, we recognize the need for a definite understanding and agreement concerning
our patient’s health care and financial arrangements for that medical care. Your clear understanding of our financial policies is
important to our professional relationship. Please contact our billing office regarding any questions about our fees, financial
policies, or your insurance coverage and your responsibilities.
Professional Fees: Our fees for medical services are comparable to other similarly trained physicians in the community and reflect
the complexity of your specific needs, the physician time dedicated to your care, the specialized nature of the doctor’s training and
education, supplies, and support costs associated with providing and coordinating your care.
Insurance: It is the patient’s responsibility to provide us with current insurance information. For verification, please have your
current insurance card and photo ID available at every appointment. As a courtesy, we will file claims to your insurance company.
Your insurance coverage is a contract between you and your insurance plan. Knowing your insurance benefits – including
eligibility and covered benefits is your responsibility; please contact customer service at your insurance company for questions you
may have regarding your coverage.
Patient Balance: All co-payments and past due balances are due at the time of check-in unless previous arrangements have been
made with our billing department. We can extend interest free, short-term financing. Depending upon your balance and the
services rendered, we can offer six (6) and twelve (12) month plans. Please contact our billing department to discuss this further.
Payment may be made by cash, check, VISA, MasterCard or Discover.

We also provide the option of keeping your credit card on file to use for account balance after insurance processing (upon receiving
explanation of benefit) which can include but are not limited to co-payment, coinsurance or deductible. You will be contacted by
the billing department of any credit card transactions.
Card Type __________________
Card # _____________________________________ Exp. Date _________________
Card Holder’s Name (print) _________________________________ Signature ___________________________________
Failure to comply with these payment policies may result in your account being reviewed to be referred to an outside collection
agency.
Patients without Insurance: For those patients that do not have insurance coverage, a prompt pay discount can be offered. Please
contact our billing department for additional details.
Cancellations/Rescheduling Appointments: Once your appointment time has been reserved for you, we trust that you will be
present. To assist patients with access to our physicians, our office does require 24 hour notice to cancel/reschedule appointments.
If we do not receive such notice, you will be charged $50 for any missed appointments. Cancellation fees are not covered by
insurance and these charges will be your responsibility and billed directly to you.
Medical Forms (FMLA, Work Comp, etc): The completion of disability forms, attending physician statements and other
supplemental insurance forms require additional physician and staff time. The first form will be no charge to you. A recurring fee
of $25.00 will be charged for additional forms.
Collection Agencies: If it becomes necessary to place your account with a third party collection agency due to your non- payment,
the account of the person responsible will be turned over to collections.
Non-Sufficient Funds: A $35.00 fee will be charged for each check returned by the financial institution. You may be placed on a
cash or credit card payment method following any returned checks and you must pay any balance due immediately.
Your signature on this page constitutes an agreement to this policy.
Please keep in mind our doctors are general and trauma surgeons. There will be times when our doctors may be called out
of the office unexpectedly. We appreciate your understanding and patience if this occurs during your appointment time.
I have read and understand the financial policy of this practice, and I agree to be bound by its terms. I authorize payment
directly to Center of Surgical Specialists, PC, for medical benefits.
Signature of Person Responsible for Account/Patient ________________________________________ Date __________
Printed Name _____________________________________________________
Witness __________________________________________________________

Source: http://www.denverobesitysurgery.com/pdf/health-questionnaire.pdf

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