IF YOU DO HAVE REFLUX OR HEARTBURN (GERD) PLEASE ANSWER THE FOLLOWING:

How frequently do you suffer from reflux symptoms?

Have you been tested for diagnosis of GERD?

If yes, please specify which tests and approximate date:

Do you take medications for reflux/heartburn?

If yes, which medications, how frequently and at what dose?

If you DO have hiatal hernia, how was the diagnosis made?

Have you ever suffered any of the following?

At what age did your weight first become a concern for you?

What is the highest weight you have ever been (outside of pregnancy)? and What year was that?

What has been your lowest adult weight?

Has anyone in your immediate family (parents, siblings) struggled with obesity?

PREVIOUS WEIGHT LOSS ATTEMPTS

GENERAL WEIGHT RELATED QUESTIONS:

What is your primary reason for seeking bariatric surgery? (e.g., health issues, aesthetic goals, quality of life)

Describe your eating and exercise habits (e.g. regular activity, irregular activity, no exercise activity, binge eating, eating large portions, carb and sweet cravings, etc) :

When did you first notice weight becoming a problem? (Childhood, Teen, Adult, Post-pregnancy, etc.) Please share any details about your weight journey:

MEDICATIONS/HERBAL SUPPLEMENTS:

If you take more than seven medications or herbal supplements, please list them below:

Do you take medications such as Plavix, Coumadin, Rivaroxaban Acetylsalicylic Acid/Aspirin (ASA) or any Nonsteroidal Anti-Inflammatory Drugs (NSAIDS)?

Yes

Have you had any other abdominalsurgery (ies)?

Yes

If yes, please specify:

Have you had any adverse reaction to anesthesia?

Yes

If yes, please specify:

Do you have dental implants, dentures, or caps?

Yes

If yes, please specify:

Have you had any type of accident or injuries?

Yes

If yes, please specify:

Have you been hospitalized for any reason besides surgeries or injuries?

Yes

If yes,Why and When?

Are you currently pregnant?

Yes

Number of pregnancies:

Do you use any type of contraceptive method?

Yes

If yes, please specify:

What is the date of your last menstrualcycle?

Do you suffer from any hormonal imbalance such as PCOS (Polycystic Ovarian Syndrome)

Yes

FAMILY HEALTH HISTORY

Please check diseases known to have occurred to any other family members such as grandparents, aunts, and uncles mainly:

If any diseases were checked can you specify who suffers/suffered from them?

Previous Occupation:

Do you use tobacco products? (Cigar, cigarette, vape, chewable, etc.)

Yes

If Yes, how much? How long?

Do you drink alcohol?

Yes

If Yes, type (beer, hard liquor, etc), how much or how often?

Do you use/used recreational drugs?

Yes

Do you have any kind of physical hobbies? (i.e.: horseback riding,car racing, golf, any kind of sport,etc.). Please Specify:

WEIGHT RELATED HISTORY

Have you ever had previous weight loss surgery?

Yes

If yes, please specify which and when?

Have you received physician-supervised treatment for obesity?

Yes

If yes, please specify:

Have you ever taken Phenteramine, Xenical or Meridia?

Yes

If yes, please specify:

Have you ever taken any other medication for weight loss?

Yes

If yes, please list:

Have you ever attended a support group for obesity?

Yes

If yes, where and for how long?

What is your actual level of activity?

Please specify your shirt size:

Please specify your pants size:

Do you have any of these characteristics?

Do you experience shortness of breath?

Yes

If yes, with what intensity/kind of activity do you experience this:

How many pillows do you use to sleep?

Do you experience chest pain or pressure upon exertion?

Yes

Do you suffer Lower Extremity Swelling?

Yes

If yes, under which activities or at what time of the day?

How long does this swelling last?

Do you suffer/suffered from any kind of lung disease?

Is there anything else we missed to ask and you would like to add?

How did you hear/know about us?

I understand that success of any bariatric procedure depends on my commitment to dietary changes, temporary or lifelong vitamin supplementation (depending on procedure), regular exercise, and consistent medical follow-up. I have answered these questions truthfully and to the best of my ability. I certify by sending this form that I am not pregnant.

Patient Health History

GENERAL INFORMATION

CONTACT INFORMATION

EMERGENCY CONTACT

HEALTH HISTORY INFORMATION

GENERAL WEIGHT RELATED QUESTIONS:

MEDICATIONS/HERBAL SUPPLEMENTS:

ALLERGIES:

OPERATIONS:

FOR WOMEN ONLY

FAMILY HEALTH HISTORY

SOCIAL HISTORY

WEIGHT RELATED HISTORY

PSYCHIATRIC

CARDIOLOGIC

PNEUMOLOGY