Bariatric Intake Packet - Summit Medical Group

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Bariatric Intake PacketMedical History – Please check if you have or ever had any of the followingDiabetesHypertensionObstructive Sleep ApneaHigh Cholesterol / HyperlipidemiaCongestive Heart FailureHeart Disease/Coronary Artery DiseaseAnginaPulmonary HypertensionDeep Venous ThrombosisPulmonary EmbolusAsthmaPeripheral Vascular DiseaseLeg Edema GallstonesReflux/HeartburnFatty LiverHiatal HerniaGoutBack painArthritisPolycystic Ovarian DiseaseMenstrual IrregularitiesFibromyalgiaDepressionOther Mental IllnessStress Urinary incontinenceOther medical conditions:Surgical History – Please list any surgeries that you’ve had Allergies – Please list all your allergiesGallbladder removalHernia surgeryAnti-reflux surgeryAbdominoplastyJoint surgeryUrinary incontinence surgeryHysterectomyOther:Family History – Please check if any relative has/had DiabetesHeart DiseaseHigh Blood PressureObesityCancerTuberculosisBleeding TendenciesStrokeOther:Page 1Social HistoryOccupation:Do you use Tobacco? Yes NoIf yes how much:Do you use Alcohol? Yes NofIf yes how much:Do you use any illicit Drugs? Yes NoIf yes how much:Form # 825 (Created 7/2020)

Symptoms – Check symptoms you currently have or have had in the pastGENERAL Chills Fever Headache Loss of Sleep Loss of Weight SweatsEye, Ear, Nose, Throat Blurred vision Difficulty swallowing Earache Hoarseness SinusitisGASTROINTESTINAL BloatingBowel tal bleedingGENITO-URINARY Blood in urine Frequent urination Lack of bladdercontrol Painful urinationMuscle/Joint/BonePain, weakness, numbness in Arms Neck Back Hips Legs Feet HEART/LUNGChest painChronic coughCoughing up of bloodInability to breath when lying flatShortness of breathWheezingSnoringDaytime SleepinessMedications – Please list all your current medicationsMedication: Dosage: How often:Medication: Dosage: How often:Medication: Dosage: How often:Medication: Dosage: How often:Medication: Dosage: How often:Medication: Dosage: How often:Medication: Dosage: How often:Medication: Dosage: How often:Weight History – Please fill out completelyNormalOverweightObeseChildhood (1-12 y.o.) Adolescence (13-18 y.o.) Young Adulthood (19-30 y.o.) Adulthood ( 30 y.o.) Page 2Weight over last 5 yearsCurrent Year1 year ago:2 years ago:3 years ago:4 years ago:5 years ago:Form # 825 (Created 7/2020)

The following questions are intended to find out what you already know about surgery forclinically severe obesity. Make sure to complete this form before your scheduledappointment.1. After surgery, how much food will you be able to eat at one time?2. How much weight do you expect to lose within one year of surgery?3. Can any person who is overweight have weight loss surgery?4. What are the risks of weight loss surgery?5. After losing a enough weight, do you need to have a second surgery to “undo” the weight lossprocedure?6. Approximately how long does weight loss surgery take to perform?7. Approximately how long will you be hospitalized after the procedure?8. Is it possible to “out -eat” the effects of weight loss surgery?9. Must you continue to see a doctor regularly after surgery?10. Will you need to make lifestyle changes after surgery?11. At what age did you develop a weight problem?Additional Questions12. What is the most that you have weighed?13. How much weight do you think you need to lose?14. How does your weight influence your lifestyle?15. How does your weight influence your Health?16. Do you suffer from Depression? If yes, how do you think surgery and its resulting weight loss wouldaffect your depression?17. Do you participate in any exercise activity? if so, what type of exercise do you do? How long do youexercise for? How often do you exercise?Page 3Form # 825 (Created 7/2020)

Diet HistoryProgramYearWeight LostWeight RegainedLength ofProgramCostWeight WatchersRichard SimmonsLA DietSlim fastJenny CraigTrim spaThe ZoneSugar BustersAtkin’s DietSouth Beach DietNutri-SystemOpti fastPage 4Form # 825 (Created 7/2020)

TOPSDiet CenterDiet PillsLiquid DietsLow calorie DietsDietician consultPhysicians weightlossHypnosisAcupunctureJaw WiringFad e 5Form # 825 (Created 7/2020)

Approximately how long does weight loss surgery take to perform? _ 7. Approximately how long will you be hospitalized after the procedure? _ 8. Is it possible to "out -eat" the effects of weight loss surger y? . Diet Pills . Liquid Diets . Low calorie Diets Dietician consult Physicians weight loss Hypnosis . Acupuncture Jaw Wiring .

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1. Bariatric Clear Liquids: starts the day after surgery. 2. Bariatric Full Liquids: starts the day you go home from the hospital. 3. Bariatric Pureed Food: starts at your 2-week post-op clinic visit. 4. Bariatric Soft Foods: lasts about 2 weeks for Bypass and 4 weeks for the Sleeve. 5. Bariatric Regular diet: Begins at your 2-month post-op .

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at the Mercy Bariatric Center Office in Washington, MO. Our office will contact you by telephone for your initial consultation. If you have questions concerning the packet, please call our Mercy Bariatric Center Coordinator - Cathy Radford, RN at 636-861-7891. Good luck on your journey, The Mercy Bariatric Center Team Mercy Bariatric Center

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Bellevue Bariatric Program January 2019 Bariatric Life-long Support We are pleased to announce the bariatric team now fol-lows our Kaiser member bariatric patients for a lifetime, . Weight loss surgery is a tool to help you lose weight and improve health. Utilizing the tool to its full potential re-

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HonorHealth Bariatric Center Rev. 04/2019 ii. Mail your completed packet and documentation to: HonorHealth Bariatric Center 10210 North 92nd Street, Suite 101 Scottsdale, Arizona 85258 iii. Faxed to: 480-391-3898 iv. Or Email your completed packet and documentation to: weightloss@honorhealth.com 6. When we have received your packet: