Certified Bariatric Surgeons - Gastric Sleeve Surgery Specialists
Welcome to the first step to a lifestyle change. Please answer all the required questions.
First name*
Last name*
Age*
Date of birth*
Email*
Phone*
Marital Status* SeparatedSingleMarriedDivorcedWindowed
Street Address*
City*
State/Province* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
Zip Code*
Country*
Sugery Request* Gastrict SleveGastric BypassDuodenal SwitchMini Gastric BypassGastric Balloon - InGastric Balloon - OutGastric Balloon AdjustmentLap-BandLap-Band RemovalLap-Band RevisionRevision: Gastric Sleeve to Gastric BypassRevision: Gastric Sleeve to Duodenal SwitchRevision: Gastric Sleeve to Mini Gastric BypassRevision: RNY Gastric BypassUndecided
Date of surgery*
Have you had any previous surgery? YesNo
If 'yes' please list surgeries
Congential abnormalities YesNo
Significant hospitalization YesNo
Other serious ilness YesNo
Cancer YesNo
Prior Surgery YesNo
Chickenpox YesNo
Tuberculosis YesNo
Stroke YesNo
Diabetes YesNo
Rheumatic fever or heart disease YesNo
If you have answered yes to any of the above questions, please list the details below if appropriate:
Please list doses and the interval taken, name of medication, dose and number of times taken per day:
Please indicate if any blood relative had any of the following conditions:
Peptic Ulcer Disease YesNo
Colon polyp(s) YesNo
Colon diverticulosis YesNo
Colitis or Crohn's Disease YesNo
Pancreas disorder YesNo
Liver disease YesNo
Heart trouble YesNo
Bleeding tendency YesNo
Arthritis YesNo
Convulsions or seizures YesNo
Anemia YesNo
Kidney disorder YesNo
Please complete the following information regarding your close relatives: if deceased, please enter age at death and cause of death:
Father DeceasedAlive
Mother DeceasedAlive
Please enter any other important family history not listed above:
Drinking alcohol NeverRarelyModerately
How often?
Smoking NeverPreviously smokedPresently smoking
Do you drink coffee? YesNo
Cups per day
Are you exposed to fumes, dust or solvents? YesNo
What is your job/ occupation?
Mark all the appopiate NSAID's (such as ibuprofen, naprosen. eg. Advil, Aleve, etc)Anticoagulants (such as Coumadin or Warfarin) TranquilizersAcetominophen (such as Tylenol)Alternative or Complementary medsDiet aids, supplements or prescriptionsNSAID's (such as Vioxx and Celebrex, etc) Cortisone / Steroids / ACTHHypotensives (high blood pressure medicines) Aspirin AntibioticsHerbals Supplements
Antibiotics (Allergic) PenicillinSulfa drugs
Other
Narcotics MorphineCodeineDemerol
Anesthetics Novocaine
Analgesics Aspirin / Empirin
Serums Tetanus antitoxin
Foods EggsMilkShellfish
Other drugs or medication:
Height
Weight
BMI
Recent weight change YesNo
Good health in general YesNoUnknown
Fevers YesNo
Chills YesNo
Change in appetite YesNo
Rash YesNo
Frequent infection or boils YesNo
Pain with swallowing YesNo
Trouble swallowing (eg. food sticks in the throat) YesNo
Regurgitation of food YesNo
Belching YesNo
Nausea YesNo
Peptic Ulcer Disease (stomach or duodenum) YesNo
Vomiting food or blood YesNo
Surgery to the esophagus YesNo
Surgery to the stomach YesNo
Surgery to the small intestines YesNo
Surgery to the large intestines (colon) YesNo
Bloating YesNo
Abdominal pain YesNo
Pain after meals YesNo
Food intolerance YesNo
Gall bladder disease (e.g. surgery or gallstone) YesNo
Jaundice YesNo
Hepatitis YesNo
Blood Transfusion YesNo
Pancreas Disease YesNo
Constipation YesNo
Diarrhea YesNo
Laxative use YesNo
Black colored bowel movements YesNo
Colitis YesNo
Crohn's Disease YesNo
Diverticulosis YesNo
Polyps YesNo
Recent change in bowel habits YesNo
Painful bowel movements YesNo
Blood in the stool YesNo
Mucus in the stool YesNo
Pus in the stool YesNo
Fistula YesNo
Hemorrhoids YesNo
Anal fissures YesNo
Anal pain or cramps YesNo
Anal itching YesNo
Bowel movements in the late night YesNo
Irregular bowel movements (inability to control timing) YesNo
Skin Disease YesNo
Hives YesNo
Eczema YesNo
Abnormal Pigmentation YesNo
URI (cold) presently YesNo
Spitting up blood YesNo
Chronic or frequent cough YesNo
Asthma YesNo
Wheezing YesNo
Difficulty breathing YesNo
Any trouble with lungs YesNo
Pleurisy YesNo
Pneumonia YesNo
Gynecological YesNot Applicable
Age started / year
Age Duration / Days/ year
Frequency (days)
Pregnancies
Miscarriages
Date of first day of last period
Endometriosis YesNo
Stiffness YesNo
Thyroid trouble YesNo
Do you wear contacts? YesNo
Eye disease or injury YesNo
Double vision YesNo
Headaches YesNo
Glaucoma YesNo
Itchy eyes or nose YesNo
Sneezing or runny nose YesNo
Nosebleeds YesNo
Chronic sinus trouble YesNo
Ear disease YesNo
Impaired hearing YesNo
Dizziness YesNo
Transient episodes of unconsciousness YesNo
Chest pain or angina pectoris YesNo
Shortness of breath with walking YesNo
Shortness of breath with lying down YesNo
Difficulty walking two blocks YesNo
Heart trouble or heart attacks YesNo
High blood pressure YesNo
Swelling of hands YesNo
Swelling of feet YesNo
Swelling of ankles YesNo
Heart murmur YesNo
Awakening at night smothering YesNo
Valvular heart disorder YesNo
Frequent urination YesNo
Loss of urine YesNo
Night time urination YesNo
Burning or painful urination YesNo
Blood in the urine YesNo
Kidney trouble YesNo
Kidney stones YesNo
Varicose veins YesNo
Weakness of joints YesNo
Any difficulty walking YesNo
Claudication YesNo
Back pain YesNo
Ever had psychiatric care? YesNo
Ever advised to see a psychiatrist? YesNo
Fainting spells YesNo
Convulsions YesNo
Paralysis YesNo
Are you slow to heal after cuts? YesNo
Blood disease YesNo
Iron deficiency YesNo
Iron overload YesNo
Phlebitis YesNo
Abnormal brusing YesNo
Abnormal bleeding YesNo
Thalassemia YesNo
Thyroid disease YesNo
Hormone therapy YesNo
Change in hat or glove size YesNo
Any change in hair growth YesNo
High cholesterol YesNo
High triglyceride YesNo
Dry skin YesNo
Hot intolerance YesNo
Cold intolerance YesNo
History of excessive bleeding (after tooth extraction or surgery) YesNo
Have you ever been in any kind of counseling or therapy? Please describe:
Are you or have you ever been under a psychiatrist's care? If yes, what was your diagnosis?
Have you ever participated in a support group? Please describe:
Are you or have you ever taken psychiatric medications? Please describe and for what purpose:
How long has excess weight been an issue in your life?
What methods have you tried to lose weight?
What do you hope to obtain from this surgery?
What are some of the changes you want to make in your lifestyle upon having this surgery?
