Bariatric And Metabolic Weight Loss Center Weight Loss .

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Bariatric and Metabolic Weight Loss CenterWeight Loss Program Questionnaire:Please complete this questionnaire and bring it with you to your appointment with thepractitioner. This information will assist us in your care plan. Thank you.Full Name: Date of Birth:Gender:FemaleMaleAddress:City, State, Zip:Home Phone:Work Phone :Cell Phone:Email:Date Attended Seminar:Race: (please circle all that icIslander/HawaiinNative AmericanOtherOperation/Procedure Requested: Roux-en-Y Gastric Bypass Sleeve Gastrectomy Adjustable Gastric Banding Gastric BalloonSurgeon Requested:Hospital Requested: v-Bloc Aspire Assist Other Undecided Dr. Pryor Dr. Spaniolas Dr. Bates Dr. Docimo First Available Stony Brook University Hospital Brookhaven Memorial Hospital I’m not interested in surgery; seeking supervised medical weight loss program. My physician A friend Facebook Internet Stony Brook’s Website Brochure Newspaper OtherHow did you hear about our program?Primary Care/Family Physician:Practice Name:Address: City, State, Zip:Office Phone: Office Fax:Referring Physician (if different from above):Practice Name:Address: City, State, Zip:Office Phone: Office Fax:7/2017Stony Brook Medicine Bariatric and Metabolic Weight Loss Center(631) 444-BARI (2274)

Please indicate if you are now experiencing or in the past year experienced any of the symptoms listed below.GENERALHEAD, EARS, EYESWeight ChangeFatigueFever/Chills/SweatsMore/less EnergySleeping ProblemsNOSE, THROATHeadacheVision ProblemsEye Pain/Rubor/TearsGlaucoma/CataractsTinnitus/Ear PainStuffy Nose/SinusesNasal Discharge/BloodTooth/Gum ProblemsDry MouthSore ThroatHoarsenessSwollen NodesSKINRashes/lumps/lesionsColor ChangeHair/Nail ChangeItchingSkin irritation/breakdownCARDIO-VASCULARChest PainPalpitationsLight HeadednessLeg pain with exerciseLeg crampsVaricose VeinsHypertensionRESPIRATORYCoughSputum Color/BloodSOBPainful BreathingWheezingShortness of breathwith activitySleep ApneaHEMEC!otting HistoryAnemiaBruising/BleedingTransfusions/Issues withBlood ProductNeck lumpsGASTRO-INTESTINALAbdominal PainDifficulty SwallowingHeartburn/IndigestionNausea/Vomit (blood?)Diarrhea/ConstipationBlood in StoolJaundice (yellow skin)MUSCULOSKELETALMuscle/JointPain/StiffnessBack PainJoint SwellingNeck P a i nN eck StiffnessHair LossENDOCRINEHeat/Cold IntoleranceExcessive Sweatinglncreased ThirstShoe/Glove Size ChangePSYCHAnxiety/NervousnessDepressionMemory ProblemsDisturbing ThoughtsQuality of Life ConcernRENALChange UrineFreq/urgencyNocturialncontinencePainful UrinationChange in Urine ColorBlood/DischargeKidney StonesPrevious/Current UTIREPRODUCTIVEPrevious/Current STIRash/ltch aroundGenitaliaProblems with SexMenstrual ChangesPrev/CurrentPregnancyOCP umbness/tinglingMEDICAL HISTORYPlease indicate if you have been diagnosed with any of the following illnesses:Heart AttackCOPDSmall BowelEpilepsy/SeizuresCardiac DiseaseAsthmaObstructionNeurological DiseaseCADSleep erthyroidAnxietyHyperlipidemia/ high Reflux/GERDType 1 DiabetesSchizophreniaCholesterolStomach ulcersType 2 DiabetesBipolar DisorderHigh triglyceridesHiatal HerniaAutoimmuneSchizoaffectiveObesityAbdominal rlineAchalasiaWhere/ WhatPersonality DisordertypePlease indicate any other illnesses or medical history:Surgical HistoryPlease indicate any previous surgeries:Do you have pain that interferes with your daily activity? No YesIf yes, where is the pain?Please circle the number that represents your pain level:No pain 012345678910 Severe pain2

Diabetes/EndocrineDoes your Diabetes Type I/II require medication?NoYesIf yes, how frequently do you test your blood sugar?Provide examples of your fasting blood sugar:Who manages your diabetes? (Primary care, endocrinologist, etc.)Pre-DiabeticNoYesHistory of Gestational DiabetesNoYesExcessive Thirst or UrinationNoYesHypoglycemiaNoYesSocial HistoryEmployment Status Full TimePart TimeHomemakerStudentDisabledOccupation EmployerSelf Employed RetiredMarital Status (please circle one): SingleChildrenSeparatedDo you use?Tobacco/nicotine products(cigarettes, pipes, cigars, chewingtobacco, e cigarettes, vapes, nicotinepatches/gums/lozenges, Chantix)AlcoholDrugs/Medications NOT prescribedfor youMarriedUnemployed Not specifiedDivorcedWidowedPartneredIf YES, how much/often?YESNOYESNOYESNOpacks per day for yearsIf you quit, whenTypeFrequency:TypeFrequency:Medications and SupplementsMedication/SupplementDosage & FrequencyReasonAllergies3

Medication/FoodReactionOther AllergiesReactionWeight HistoryCurrent Weight: lbs; kg Current Height: in; cm BMI:Number of yrs overweight:Highest Adult Weight:When was your highest weight?:Lowest Adult Weight:When was your lowest Weight?Birth WeightAs best you can recall, what wasGrade SchoolHigh Schoolyour body weight at each of theAges 20-29 30-39 40-49following points of your life?50-59 60-69What is the most weight you lost?When did you lose this weight?How long did you keep this weight off?Method used for this weight lossHave you had previous bariatric surgery?Weight History CommentsActivity/ExerciseDo you exercise regularly? Yes Types of exercise?How often? times/week times/month No If no, what prevents you from exercising? Time Strengthening Cardio Other:Work HealthOther:Family HistoryOverweight Family MembersFamily History of Heart DiseaseFamily History of Diabetes/Endocrine DiseaseFamily History of High Blood PressureFamily History of CancerFamily History of ArthritisFamily History of Early DeathFamily History of AsthmaFamily History of StrokeFamily History of DepressionOther Family Disease HistoryType:4

Sleepiness QuestionnairesHave you been diagnosed with sleep apnea?Do you use a CPAP Machine? Yes No Yes What is the setting? No, do not use.How likely are you to doze off or fall asleep in the following situations, in contrast to feeling tired? Thisrefers to your usual way of life in recent times. Even if you have not done some of these things recently, tryto work out how they have affected you. Use the following scale to choose the most appropriate number foreach situation:0 would never doze1 slight chance of dozing2 moderate chance of dozing3 high chance of dozingSitting and readingWatching TVSitting, inactive in a public place (e.g. a theater or meeting)As a passenger in a car for an hour without a breakLying down to rest in the afternoon when circumstances permitSitting and talking to someoneSitting quietly after a lunch without alcoholIn a car, while stopped for a few minutes in trafficChances of Dozing (Scale of 0-3)Collar size of shirt: S M L XL or inches/cm (15.5 inches 40 cm)1. Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?YesNo2. Tired: Do you often feel tired, fatigued, or sleepy during daytime?YesNo3. Observed: Has anyone observed you stop breathing during your sleep?YesNo4. Blood Pressure: Do you have or are you being treated for high blood pressure? YesNoFor clinical staff to complete: BMI more than 35 kg/m2Age: Age over 50 years old?Neck circumference: Neck circumference greater than 40 cm? (measured by staff)Gender: Gender maleYesYesYesYesNoNoNoNo(10 Epworth; 3 STOP BANG)5

Please fill out this part of the form with as much detail as possibleMonth/Year?WeightWeightHow long were you on the program(s)?Program(s)LossRegainedWhy did you stop the program(s)?Weight WatchersOvereaters AnonymousJenny Craig/ NutriSystem,OTC Diet PillsLA weight loss, The Diet CenterCounseling with RD,psychologist, etc.Prescription Medications:(Fen Phen, Phentremine, Redux,Meredia, Xenical, etc.)Weight Loss Shots/InjectionsHypnosisAcupunctureLow Carbohydrate DietsDiet Books/ Fad diets:Liquid diets: (Medifast, Optifast,Slimfast, Isagenix, etc.)Other:6

Do any of the following environmental issues listed below affect your weight?If so, please explain.Occupation-related eating issues: YesTravel: Yes No NoHousehold issues (family/obligations/schedule): YesShopping/cooking/etc: YesFinancial Issues: Yes No No NoMeals eaten away from home (frequency/location): YesSleep: Yes No NoDo any of the following eating behaviors listed below affect your weight? If so, please explain. Binge EatingCurrent Problem Yes NoPast Problem Yes No AnorexiaPast Problem Yes No BulimiaCurrent Problem Yes NoPast Problem Yes No Emotional EatingCurrent Problem Yes NoPast Problem Yes No Frequent CravingsCurrent Problem Yes NoPast Problem Yes No Lack ofAwareness ofHungerCurrent Problem Yes NoPast Problem Yes No Lack ofAwareness ofFullnessCurrent Problem Yes NoPast Problem Yes No7

Please answer the questions below to the best of your ability:Do you have any food allergies? Yes No If yes, what are they?Do you have any food intolerances? Yes No If yes, what are they?How often do you eat fast food/take out? Provide an example of what you would order.How often do you eat at restaurants? Provide an example of what you would order from a restaurant.How often do you eat sweets? Provide examples of sweets you consume.How often do you eat fried foods? Provide examples of fried foods you consume.Please indicate beverages consumed/amount/frequency: Water: Regular Soda: Diet Soda: Juice: Juice Drink: Crystal light/sugar free beverages: Coffee/tea : Other sugar sweetened beverages: Other:How often do you consume alcoholic beverages? What type? Amount?What types of food do you crave? How often do you eat them?How many days per week do you consume vegetables and fruits?Fruits:Vegetables:Check off the items consumed:Cheese Yes No If yes, is it Regular full fat 2% reduced fat 1% low fat 0% skim/fat freeYogurt Yes No If yes, is it Regular full fat 2% reduced fat 1% low fat 0% skim/fat freeMilk Yes No If yes, is it Regular full fat 2% reduced fat 1% low fat 0% skim/fat freeCheck off items consumed: Meat Poultry Fish Beans Tofu Nuts Eggs8

Please provide foods consumed on a typical day. Please provide information regarding portion sizes,type of foods consumes, and time meals/snacks are consumed.Example: Breakfast: 8:30 am: 2 scrambled eggs, 1 slice whole wheat toast with 1 tablespoon natural peanutbutter with 8 ounces of 1% milk.1st MealTime:2nd MealTime:3rd MealTime:Snack 1/ Time:Snack 2/ Time:Snack 3/ Time:9

Department of SurgeryPERMISSION TO EXCHANGE INFORMATIONI, HEREBY GRANT PERMISSION FOR COMMUNICATIONBETWEEN THE PROFESSIONAL STAFF OF The Stony Brook Medicine Bariatric and MetabolicWeight Loss Center, REGARDING ANY AND ALL OF MY PSYCHOLOGICAL, MEDICAL,PSYCHIATRIC, EDUCATIONAL AND SOCIAL RECORDS AS RELATED TO MYENGAGEMENT IN THE WEIGHT LOSS CENTER’S PROGRAMS AND/OR WEIGHT LOSSSURGERY INTERVENTIONS.(CLIENT’S NAME (Please print)(Signature of client or signature of guardian to client)Date:In addition, I also grant permission for exchange of information with:(Indicate name; include address and phone if possible)Witness:(Please print name)Date:(Witness Signature)10

Part 1: PHQ-4Over the last 2 weeks, how often have youbeen bothered by the following problems?More thanNearlyhalf theevery daydaysNotat allSeveraldays1. Feeling nervous, anxious or on edge01232. Not being able to stop or control worrying01233. Little interest or pleasure in doing things01234. Feeling down, depressed, or hopeless0123NoYeseat?01b. Do you often eat, within any 2-hour period, what most peoplewould regard as an unusually large amount of food?0101NoYesa. Made yourself vomit?01b. Took more than twice the recommended dose of laxatives?0101(Please circle your answer)Part 1 Total Score Part 2: Eating Behaviors5. Questions about eating(Please circle your answer)a. Do you often feel that you can’t control what or how much youIf you checked “NO” to either #a or #b, go to question #8.c. Has this been as often, on average, as once a week for the last 3months?6. In the last 3 months have you often done any of the following inorder to avoid gaining weight?(Please circle your answer)c. Fasted –– not eaten anything at all for at least 24 hours?11

d. Exercised for more than an hour specifically to avoid gainingweight after binge eating?01No0YesNo0Yes9. Have any of the following happened to you more than once in the last6 months?01a. You drank alcohol even though a doctor suggested that you stopdrinking because of a problem with your health.010101d. You had a problem getting along with other people while you weredrinking.01e. You drove a car after having several drinks or after drinking toomuch.017. If you checked “YES” to any of these ways of avoiding gainingweight, were any as often, on average, as once a week?Part 2 Total Score Part 3: Alcohol Use8. Do you ever drink alcohol (including beer or wine)?If you checked “NO” go to question #10.b. You drank alcohol, were high from alcohol, or hung over while youwere working, going to school, or taking care of children or otherresponsibilities.c. You missed or were late for work, school, or other activitiesbecause you were drinking or hung over.Part 3 Total Score11 Part 4: Symptom Interference10. If you checked off any problems on thisquestionnaire, how difficult have these problemsmade it for you to do your work, take care of thingsat home, or get along with other people?(Please circle your answer)NotSomewhatVeryat t3Part 4 Score For Office Use Only:If Part 1 Total Score is 5, Part 2 Total Score 0, Part 3 Total Score 0, and Part 4 Score 0 or 1 thenpatient can be scheduled at MB-CRC12

7/2017 Stony Brook Medicine Bariatric and Metabolic Weight Loss Center (631) 444-BARI (2274) Bariatric and Metabolic Weight Loss Center Weight Loss Program Questionnaire: Please complete this questio

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