Bariatric Patient Questionnaire

I am interested in having:
General Information
Name:		Gender:
Date of birth:	/ /	Age:
Email:		Phone:	- -
Race:		Height:	inches
Weight:	lbs.	BMI:
Who referred you to us?
Number of years overweight:
Goal weight:	lbs.	Goal clothing size:
Gastric bypass			Lap-band
Revision			Other:
How do you think your life will change by losing weight and why are you seeking bariatric surgery?

What has contributed towards the development of your obesity?

Program	Date	Duration	MD Supervised?	Weight Loss
Previous Attempts at Weight Reduction
Weight Watchers	/ /	days	No Yes	lbs.
Jenny Craig	/ /	days	No Yes	lbs.
Metabolife	/ /	days	No Yes	lbs.
Nutrisystem	/ /	days	No Yes	lbs.
Atkins Diet	/ /	days	No Yes	lbs.
Slim Fast	/ /	days	No Yes	lbs.
Optifast/Medifast	/ /	days	No Yes	lbs.
TOPS	/ /	days	No Yes	lbs.
Overeaters Anonymous	/ /	days	No Yes	lbs.
Prescription Medications	/ /	days	No Yes	lbs.
OTC Weight Loss Medications	/ /	days	No Yes	lbs.
Hypnosis	/ /	days	No Yes	lbs.
Psychotherapy	/ /	days	No Yes	lbs.
Other:	/ /	days	No Yes	lbs.

Previous weight loss surgery
Type:		Date:	/ /
Surgeon:		Location:
Start weight:	lbs.	End weight:	lbs.
Complications from prior procedure: (please list)

Type:		Date:	/ /
Surgeon:		Location:
Start weight:	lbs.	End weight:	lbs.
Complications from prior procedure: (please list)

Do you, or have you had, any of the following illnesses or symptoms?
Past Medical History
Name of Primary Care Provider:		PCP phone number:	- -
Date of last physical exam:	/ /	Date of last blood work:	/ /
Heart disease:	No Yes	If yes, year of diagnosis:
Date of last stress test:	/ /	Name of cardiologist:
Cardiologist's phone number:	- -	Heart valve disease:	No Yes
History of heart valve replacement:	No Yes
Angina (chest pain):	No Yes	Last occurrence:
Chest pain with activity?	No Yes	Chest pain at rest?	No Yes
MI (heart attack):	No Yes	Last occurrence:
Coronary bypass surgery:	No Yes	Last occurrence:
Coronary angioplasty/stents:	No Yes	Last occurrence:
Stroke:	No Yes	Last occurrence:
Congestive heart failure:	No Yes	Last echocardiogram:
Defibrillator or pacemaker:	No Yes
Atrial fibrillation:	No Yes	Medications?	No Yes
High blood pressure:	No Yes	Medications?	No Yes
Lower extremity edema (leg swelling):	No Yes	Medications?	No Yes
Leg ulceration:	No Yes
Skin changes:	No Yes
DVT (blood clots in legs):	No Yes	Year of diagnosis:
Pulmonary embolism (blood clot in lungs):	No Yes	Year of diagnosis:
Currently taking blood-thinning medications?	No Yes
Diabetes:	No Yes	Year of diagnosis:
Diet controlled:	No Yes	Oral medications?	No Yes
Insulin use:	No Yes	Last Hgb A1c:
Elevated cholesterol:	No Yes	Medications?	No Yes
Gout:	No Yes	Medications?	No Yes
Pulmonary hypertension:	No Yes
Obesity Hypoventilation Syndrome:	No Yes	Oxygen use?	No Yes
Obstructive Sleep Apnea:	No Yes	CPAP or BiPAP use?	No Yes
Tested for Sleep Apnea?	No Yes	Result:
Do you or have you had?
Snoring?	No Yes	Daytime drowsiness?	No Yes
Observed apnea spells?	No Yes	Awakening at night?	No Yes
Morning headaches?	No Yes
Asthma/COPD:	No Yes	Oxygen use?	No Yes
History of oral steroid use?	No Yes	Last use of oral steroids:
Overnight hospitalization?	No Yes	History of intubation?	No Yes
Shortness of breath:	No Yes	How far can you walk?	ft.
Esophageal reflux/heartburn:	No Yes	Medications?	No Yes
History of endoscopy (EGD):	No Yes	Date of test:	/ /
History of esophageal dilation:	No Yes	Last occurrence:
History of trouble swallowing:	No Yes
Gallstones:	No Yes	Gallbladder surgery?	No Yes
Liver disease:	No Yes	Year of diagnosis:
Do you, or have you ever had?
Elevated liver enzymes?	No Yes	Esophageal varices?	No Yes
Cirrhosis?	No Yes	Portal hypertension?	No Yes
Back or neck pain:	No Yes	Surgery?	No Yes
Limits ability to walk or exercise?	No Yes	OTC medications?	No Yes
Prescription medications?	No Yes
Joint pain:	No Yes	Surgery?	No Yes
Limits ability to walk or exercise?	No Yes	OTC medications?	No Yes
Prescription medications?	No Yes
Fibromyalgia:	No Yes	Medications?	No Yes
Connective Tissue Disease (Rheumatoid Arthritis or Lupus):	No Yes	Year of diagnosis:
Limits ability to walk or exercise?	No Yes
History of oral steroid use?	No Yes	Last use of oral steroids:
Reproductive Disease:	No Yes	History of infertility?	No Yes
PCOS:	No Yes	Medications?	No Yes
Irregular Menses (not PCOS):	No Yes	Last normal menstrual period:
Urinary incontinence:	No Yes	Medications?	No Yes
Pseudo tumor cerebri:	No Yes	Symptoms:
Migraine headaches:	No Yes	Prescription medications?	No Yes
History of cancer:	No Yes	Type:
Year of diagnosis:		Type of treatments:
Abdominal hernia:	No Yes	Hernia present now?	No Yes
Incisional hernia:	No Yes	Umbilical hernia:	No Yes
Prior hernia repair:	No Yes	List type and dates:	/ /
Psychosocial History
Do you smoke?	No Yes	When did you quit?
Number of packs per day:		Number of years smoking:
Do you drink alcohol?	No Yes	Number of drinks per day:
Type of alcohol:		Prior history of alcohol abuse?	No Yes
How many years sober?
Do you use drugs?	No Yes	Type of drugs used:
History of IV drug use?	No Yes	Last use of IV drugs:
Prior history of drug abuse?	No Yes	How many years sober?
History of mental illness?	No Yes	Currently in treatment?	No Yes
Diagnosis:	Depression	Bipolar
	Anxiety/panic	Personality disorder
	Schizophrenia	Other:
Name of psychiatrist or therapist:		Phone number:	- -
Hospitalization for mental illness?	No Yes	Last occurrence:
History of suicide attempt?	No Yes	Last occurrence:
Functional Status
When was the last time you exercised?		Type of exercise:
What keeps you from exercising?
Do you walk with assistance from the use of?
Cane or crutch?	No Yes	Wheelchair?	No Yes
Walker?	No Yes	Other:
Other Medical History
Please list all other medical illnesses not previously mentioned:

Please list all non-surgical hospitalizations you have experienced as an adult:

History of blood transfusion?	No Yes	Indication and date:	/ /
History of hepatitis?	No Yes	Type:
Ever exposed to HIV/AIDS?	No Yes
Past problems with anesthesia?	No Yes	Complication:
Could you be pregnant?	No Yes	Last normal menstrual period:
Past Surgical History (please list all surgical procedures or operations)
Procedure	Indication	Hospital	Date
			/ /
			/ /
			/ /
			/ /
			/ /
Allergies
Are you allergic to
Latex?	No Yes	Adhesives?	No Yes
Iodine?	No Yes	IV contrast?	No Yes
Are you allergic to any medication?	No Yes
If yes, please list medications and reactions (e.g. rash, breathing difficulty, shock, etc.):

Medications (please list ALL medications, prescription and OTC, and dosages that you currently use):

Social History
Marital Status	Married	Single
	Divorced	Widowed
Children?	No Yes	Number:
Who do you live with?
Who supports you in your decision to have bariatric surgery?
Highest level of education completed:
Occupation:
If disabled, year became disabled:		Cause of disability:

Condition	Mother	Father	Brother	Sister	Children
Family Medical History
Obesity	Yes	Yes	Yes	Yes	Yes
Weight loss surgery	Yes	Yes	Yes	Yes	Yes
Heart attack	Yes	Yes	Yes	Yes	Yes
High blood pressure	Yes	Yes	Yes	Yes	Yes
Diabetes	Yes	Yes	Yes	Yes	Yes
Cancer	Yes	Yes	Yes	Yes	Yes
Stroke	Yes	Yes	Yes	Yes	Yes
Blood clots	Yes	Yes	Yes	Yes	Yes
Substance abuse	Yes	Yes	Yes	Yes	Yes
Problems with anesthesia	Yes	Yes	Yes	Yes	Yes

Health Maintenance
Date of last Pap Smear:	/ /	Result:
Date of last Mammogram:	/ /	Result:
Date of last Bone Density Screen/DEXA Scan:	/ /	Result:
Date of last Prostate exam:	/ /	Result:
Date of last Colonoscopy:	/ /	Result:

Constitutional
System Review (please mark any of the following you have experienced in the past)
Fatigue	Tiredness	Recent weight loss	Fever
Night sweats	Abnormal bleeding
Head and Neck
Blurred vision	Double vision	Loss of vision	Loss of hearing
Dizziness	Vertigo	Sinus congestion	Runny nose
Sneezing	Loss of smell	Sinus infections	Sore throat
Hoarseness	Lump in neck	Difficulty swallowing	Pain when swallowing
Cardiovascular
Chest pain	Palpitations	Pain in arms or neck	Heart pounding
Heart murmur	Abnormal heartbeats	Low blood pressure	Pain in legs
Cold feet	Loss of pulses
Respiratory
Cough	Wheezing	Bloody sputum	Bronchitis
Pneumonia	Difficulty sleeping flat	Shortness of breath	Waking at night
Gastrointestinal
Jaundice	Nausea	Hepatitis	Cirrhosis
Vomiting	Heartburn	Abdominal pain	Diarrhea
Constipation	Colitis	Blood in stool	Painful bowel movements
Hemorrhoids	Change in stool	Irritable bowels
Genitourinary
Blood in urine	Frequent urination	Leakage of urine	Pain with urine
Kidney stones	Trouble starting urine	Bladder infection	Penile discharge
Loss of erection	Vaginal discharge
Musculoskeletal
Pain in joints	Muscular aches	Swelling in joints	Arthritis
Low back pain	Sciatica	Herniated disk	Numbness
Endocrine
Hyperthyroid	Low thyroid	Swollen glands	Diabetes
Prior radiation	Adrenal gland tumor	Previous steroid use or injections
Skin/Breast
Skin cancer	Burns	Rash	Abnormal moles
Breast mass	Nipple discharge
Neurological
Seizures	Convulsions	Fainting	Dizziness
Lightheadedness	Tremors	Falling	Numbness
Muscle weakness	Strokes	Loss of consciousness
Psychological
Depression	Nervousness	Anxiety	Suicidal thoughts
Suicide attempts	Anorexia	Bulimia	Binge eating
Hospitalization for emotional problems	Schizophrenia	Insomnia	Psychiatric or psychological counseling