HonorHealth Bariatric Center
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)HonorHealth Bariatric CenterMail completed packet to:10210 North 92nd Street, Suite 101Scottsdale, Arizona 85258480-882-7460Or Email to:weightloss@honorhealth.comSeminars are available online and in-person at the HonorHealth Shea Medical Centerlocation.Visit Honorhealth.com/bariatrics to register.Patient History QuestionnaireHonorHealth Bariatric CenterPage 1 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)Congratulations!By considering the option to undergo weight loss surgery, you have taken the first step necessary tochange your health.and your life. Please read the following information carefully.Please do not print the packet double sided.Steps in the Process:1.You must attend one of our free public educational seminars. A list of our current seminarsis located on our website Honorhealth.com/bariatrics or call 623-580-5800.2.Confirm your insurance coverage for weight loss surgery.Patients Paying Cash:Patients who have decided to pay cash either because they have no insurance benefit or becausethey do not want or are not able to meet the requirements of their insurance company go directly to#3 below.If you are going to use insurance to pay for your surgery:Contact your insurance carrier to determine whether you have a weight loss benefit as part ofyour insurance coverage.Your insurance company may require a medically supervised weight loss program. You may opt towork within our system of care or with your primary care physician to complete your supervisedweight-loss program.OUT OF NETWORK:If we are not a contracted provider for your insurance company, you may still choose to completeour program.All charges would be subject to your out-of-network benefits.3. Complete and submit your new patient packet.You must completely fill out your new patient packet and sign it in order for us to determinewhether you’re a candidate for surgery at the HonorHealth Bariatric Center. Please complete thispacket in ink or typed. Include a copy (front and back) of your insurance card with your completed packet.4. Support documentation is now required by all insurance companies for HMO, POS and PPOtype plans. You will need to provide: A letter from a physician supporting your decision to undergo weight loss surgery. The physician will refer to this as a letter of medical necessity. We have attached a copy of asample letter that you can give to your primary care doctor to complete. If your insurance company requires a supervised medical weight loss period, we can helpby having you work with our medical weight loss specialist. This program is covered by most insurance plans.5.Submitting your completed packet:You can bring the packet, insurance information and supporting documentation tothe public seminar, ori.Patient History QuestionnaireHonorHealth Bariatric CenterPage 2 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Nameii.iii.iv.6.Mail your completed packet and documentation to:HonorHealth Bariatric Center10210 North 92nd Street, Suite 101Scottsdale, Arizona 85258Faxed to: 480-391-3898Or Email your completed packet and documentation to:weightloss@honorhealth.comWhen we have received your packet: 7.(The patient completes all informationrequested except when indicated.)We will verify your insurance benefit, co-pay and eligibility requirements. Ourpatient liaison will then call you to answer any questions you may have and help youdevelop a plan to complete the program. (Please allow 10-14 business days for this)For patients who are not using insurance to pay for the surgery, our patient liaisonwill call you to schedule your initial consultation and answer any remainingquestions you may have.All patient packets are evaluated for possible medical problems or special situations thatmight require a different pathway of care.Your initial consultation will include: A comprehensive health history and physical evaluation by the surgeon. A nutritional evaluation by one of our staff Registered Dietitian. This is now required by allinsurance companies in order to obtain an authorization for surgery. All patients must complete a comprehensive psychological evaluation and testing by aLicensed Clinical Psychologist specializing in Bariatric surgery prior to surgeryo If you do not wish to see our in-house psychologist or unable to per your insuranceguidelines, you will be given a list of psychologists that we work with in order tocomplete this requirement. An exercise consultation by our staff Exercise Physiologist. Your initial appointment at HonorHealth Bariatric Center will last approximately 2-4 hours.We will email you the confirmation of your appointment and a map to our office. If you cancelor reschedule an appointment please give several days’ notice.PLEASE REMEMBER: If you did not submit a letter of medical necessity from your Primary CarePhysician supporting your application for surgery, or your medically supervised weight lossdocumentation, you MUST bring it with you to your initial consultation.AUTHORIZATION for surgery cannot be submitted without these documents.That’s it! You’re now on your way to better health. While it’s understandable that you may be anxiousto schedule this life-changing event, we thank you for your patience during the process. AtHonorHealth Bariatric Center, we take every precaution to ensure your health, safety and longterm success.Patient History QuestionnaireHonorHealth Bariatric CenterPage 3 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)New Patient Registration Form – Demographics and InsuranceHeight: Current Weight:Patient: Name: First Middle LastAliases (other names you may go by):SSN: ( - - ) Date of Birth: ( / / ) Sex: M FPatient street address and number:Patient address additional:City: , State: , ZIP: -Primary Phone Number: ( ) -Mobile Home WorkSecondary Phone Number: ( ) - Mobile Home WorkEmail address:What is your preferred language? Interpreter Required? Yes NoAre you Hearing impaired? Yes NoAre you visually impaired? Yes NoMarital Status:Divorced Legally Separated Married Other Sig. Other Single WidowedReligious preference: I prefer to not answerMother’s Maiden Name: I prefer to not answerThe government requires that we ask the following 2 questions:1) How do you identify your ethnicity?Hispanic or Latino,Not Hispanic or Latino,I prefer to not answer.2) How do you identify your race?American Indian or Alaska NativeBlack or African American,Native HawaiianOther Pacific Islander White or CaucasianAsianI prefer to not answerWho is your Primary Care Physician?Contact information of the Primary Care Practice:Phone #:Employment Status: Full-Time Part-Time Retired Disabled Student UnemployedEmployer Name:Occupation:Patient History QuestionnaireHonorHealth Bariatric CenterPage 4 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)How many employees work at your company?1-1920-99 100 Don’t knowWho would you like to list as an emergency contact?Name: Date of Birth: ( / / ) Sex: M FAddress:Relationship to you:Phone Number: ( ) -Mobile Home WorkWho is the guarantor of your account? (Who is financially responsible for any amount notpaid by the insurance company?) Please write “self” if it is you.Guarantor: Name: First Middle LastSSN: ( - - ) Date of Birth: ( / / ) Sex: M FAddress:Phone Number: ( ) -Mobile Home WorkPrimary Insurance:Medical Insurance Company Name:Member/Subscriber Identification #: Group #:Medical Insurance Company Address:Medical Insurance Customer Service Phone #: ( ) -Relationship of the insurance subscriber to the patient:Self Parent Spouse Other:Subscriber: Name: First Middle LastSSN: ( - - ) Date of Birth: ( / / ) Sex: M FAddress:Phone Number: ( ) - Mobile Home WorkEmployer Name:Occupation:How many employees work at your company?1-1920-99 100 Don’t knowDo you have any additional insurance? Yes NoSecondary Insurance:Medical Insurance Company Name:Member/Subscriber Identification #: Group #:Medical Insurance Company Address:Medical Insurance Customer Service Phone #: ( ) -Relationship of the insurance subscriber to the patient:Self Parent Spouse Other:Subscriber: Name: First Middle LastPatient History QuestionnaireHonorHealth Bariatric CenterPage 5 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)SSN: ( - - ) Date of Birth: ( / / ) Sex: M FAddress:Phone Number: ( ) - Mobile Home WorkEmployer Name:Occupation:How many employees work at your company?1-1920-99 100 Don’t knowPlease present all insurance cards for copying.How did you hear about HonorHealth Bariatric Center? (Please check one) Electronic Newspaper Physician referral Family Radio Friend Search Engine Magazine T.V. Newspaper Website Other (please explain)Have you attended a HonorHealth Bariatric Center Informational Seminar? No Yes When and Where?Have you had a previous bariatric surgery or procedure? Yes NoType of Surgery: Date Performed:Where and Name of your surgeon?Current Complications with the surgery?What procedure are you interested in?Bypass Sleeve LapBand Revision Other:Clinical Study Participation:HonorHealth Bariatric Center strives to provide our patients with various methods ofachieving weight loss and is currently participating in clinical trials of new devicesbeing tested for use in overweight/obese patients. If you are interested inparticipating in one of these clinical trials or want to discuss participation, check thisbox. Yes, I am interested in learning more about the clinical studies being performedat HonorHealth Bariatric Center. No, I am not interested at this time. Have you or are you currently participating in a clinical trial? Yes NoPatient History QuestionnaireHonorHealth Bariatric CenterPage 6 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)Please fill out if you are over the age of 65 or on Medicare Disability onlyPlease check box ONLY if the answer is “YES” Are you receiving Black Lung Benefits? Are the services to be paid by a government research program? Are you entitled to benefits through the Dept of Veterans Affairs? Was the illness/injury due to a work-related accident/condition?o Date of Accident: Location: Time: Was the illness/injury due to a non-work-related accident?o Date of Accident: Location: Are you entitled to Medicare based on End Stage Renal Disease?o Time:Transplant Received? Dialysis tx? DatesAre you currently employed? If yes, place of employmentoEmployer coverage? Plan: Do you have a spouse who is currently employed? Retirement Dates (if applicable) or last date employedoPatient History QuestionnaireHonorHealth Bariatric CenterNever worked Y/NPage 7 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)New Patient Registration Form – Medical InformationWho are your current medical providers?NameSpecialty, or condition for which they treat youContact information for your pharmacy:Name:Phone #Cross Streets:Preventive CareTestAnnual PhysicalColonoscopyBone DensityDental ExamYearTestProstate ScreenPap ScreenMammogramAllergies or intolerances to medications?NameYearTestCholesterol TestDiabetes ScreenEye ExamYearReactionPlease list all medications, supplements, over the counter drugs, creams and inhalers.NameDose/StrengthFrequency takenPatient History QuestionnaireHonorHealth Bariatric CenterPage 8 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)Weight Related IllnessesHave you had, or do you have, any of the following illnesses or symptoms?1. Heart Disease Yes NoYear diagnosed(Check all that apply to you)Taking medications for heart disease [Check all that apply: ASA Coumadin Plavix] Angina M.I. (myocardial infarction) Abnormal EKG CABG (coronary artery bypass graft) Palpitations Stress test to rule out cardiac problems2. High Cholesterol Yes No Year diagnosed(Check all that apply to you) High triglycerides Taking medication for high cholesterol3. High Blood Pressure Yes No Year diagnosed Taking medications for high blood pressureAverage pressure:List dietary restrictions:4. Pre-Diabetes Yes No Year diagnosed Taking medications for pre-diabetes5. Diabetes Yes No Year diagnosed:How Diagnosed? FBG HgA1c Glucola TestWhat type? Type I Type II Don’t knowGestational . . . . . . . . . . . . . . . . . . . Yes NoControlled with . . . . . . . . . . . . . . Diet Medications InsulinLast fasting blood sugar:Date:Last HgA1c: Date:Complications of T2DM: Neuropathy Kidney Disease Vascular Disease Amputation6. Asthma Yes No Year diagnosed Taking medications for asthmaER visits in the last 2 years:Hospitalizations in last 2 years:Steroids used in last 2 years Yes No7. Reactive Airway Disease (RAD) Yes No Year diagnosedAge at diagnosis Taking medications for RADWhat exacerbates RAD?Take which inhaler for RAD?Take which steroids for RAD?Patient History QuestionnaireHonorHealth Bariatric CenterPage 9 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)8. Sleep Apnea Syndrome(Check all that apply to you regardless if you have been diagnosed with sleep apnea or not)Morning headaches . . . . . . . . . . . . . . . . . . . . Yes NoDaytime drowsiness. . . . . . . . . . . . . . . . . . . . Yes NoRestless sleep . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NoSnoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NoAwakenings at night . . . . . . . . . . . . . . . . . . . Yes No(Including choke or gasp)Observed apnic episodes . . . . . . . . . . . . . . . Yes NoLast sleep study (month/year)Have you been diagnosed with sleep apnea? . . . . . . . . . . Yes NoYear diagnosedCPAP used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NoSetting9. Barrett’s esophagitis Yes No Year diagnosed10. Hiatus herniaUpper GI series. . . . . . . . . . . . . . . . . . . . . . . . . YesEndoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes11. Gastroesophageal reflux (GERD) Taking medication for GERD Yes No Year diagnosed No No Yes No Year diagnosed12. Gallbladder disease Yes NoHow was it diagnosed? . . . . . . . . . . . . . . . . . . . . . . . Ultrasound Physical examYear diagnosedDid you have your gallbladder removed? Yes NoIf yes, was it removed: Laparoscopically Open procedure 13. Stress incontinence Yes No(Leakage of urine with laughing/coughing/sneezing)Wear pads frequently . . . . . . . . . . . Yes No14. Diagnosis of Chronic Joint Disease Yes NoHow was it diagnosed? Year:What treatments have been prescribed to you by a medical doctor (check all that apply): Physical therapy Lifestyle modification Medication Type of medication: SurgeryType of surgery:Patient History QuestionnaireHonorHealth Bariatric CenterPage 10 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name15. Can you walk unassisted?(The patient completes all informationrequested except when indicated.) Yes NoIf no, do you use a: cane . . . . . . . . . Yeswalker . . . . . . . Yeswheelchair . . . Yes No No No16. Weight related injuries and trauma17. Swelling in legs Yes No18. Thyroid disease Taking medication for thyroid disease Yes No19. Have you ever been on a blood thinner to prevent or treat the formation of blood clots? Yes No20. Do you have a personal history of blood clots in your arms, legs or lungs? Yes No Warfarin Coumadin Lovenox Heparin Other21. Do you have a personal history of problems with your blood being too thin or too thick? Yes No22. Deep Venous Thrombosis Yes No Year Diagnosed:23. Pulmonary Embolism Yes No Year Diagnosed:24. HepatitisWhich type (circle one): Yes No Year Diagnosed:A B C Unknown25. Cancer Yes No Year Diagnosed:Type:Treatment:26. Irregular period of infertility(for female patients only) Yes NoIf yes, please explain:Patient History QuestionnaireHonorHealth Bariatric CenterPage 11 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)Please list any additional health conditions you currently have:ConditionDateCommentsConditionDatePlease circle or add all major operations or myBreastAugmentationBreast SurgeryCesareanSectionHeart sReasonPatient History QuestionnaireHonorHealth Bariatric CenterCoronary ArteryStentCosmetic bes TiedHernia repairHeart ValvesurgeryOvariesYearDateThyroid SurgeryEyeFracture RepairHysterectomyCommentsCommentsPage 12 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when aternalGrandmotherPaternalGrandfatherOther: AdoptedSocial HistoryAlcohol Use Family History Unknown YES NO If NO, date of last drink: / /How often do you have a drink containingalcohol?How many drinks containing alcohol doyou have on a typical day when you aredrinking?How often do you have 6 or more drinkson one occasion?Glasses of wine per weekCans of beer per weekShots of liquor per weekMixed drinks with 0.5 ounces alcohol perweekSexual ActivitySexually active?CurrentlySexual Partners?MenBirth control used:Patient History QuestionnaireHonorHealth Bariatric CenterNever Montly or Less 2-4 times a month 2-3 times per week 4 or more times a week1-2 3-4 5-6 7-9 10 or moreNever Less than monthly Monthly Weekly Daily or almost 910 10 10 10 Not CurrentlyBothPage 13 of 23Rev. 04/2019Other:Alzheimer’sVision LossStrokeMiscarriagesMental IllnessKidney DiseaseHearing LossHigh CholesterolCOPDBirth DefectsAsthmaArthritisDrug AbuseAlcohol AbuseObesityHeart DiseaseHigh Blood PressureDiabetesDepressionCancerStatus: Alive or DeceasedMotherFatherM or FM or FM or FM or FM or FM or FM or FM or FChildren:Siblings:AgeFamily Medical History
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)Drug Use YES NO Former User Date of last use: / /AmphetaminesBenzodiazepines“Crack” Cocaine CocaineHeroinMarijuanaMethamphetaminesPCPHuff GassesNoneTobacco/Nicotine Use YES NO Quit Date: / /Type of Product: Cigarettes Cigar E-Cigarettes/ Vape Other:Smoke every daySmoke some daysFormer smokerHeavy smokerLight smokerNever smokedSecond-hand exposureIf ever smoked:How many packs/day average ½ 1 1½ 2 3 How many years smoked?Have you ever chewed or used snuff? YES NOIf you currently use any tobacco/nicotine product, are you ready to quit? YES NOAdvanced Directives (Living will and medical power of attorney)Do you have an advanced directive? YES NOWould you like information or a copy of advanced directive forms? YES NOPatient MeasurementHeightInitial Body WeightAgeWeightAfter UndergoingPubertyHigh SchoolGraduationMarriageIdeal Body WeightExcess Body Weight10% Pre-Op ExcessBody Weight Loss GoalTarget WeightBody Frame(circle one)Weight HistoryBirth WeightLowest Weight inthe Past 5 YearsHighest Weight inthe Last 5 YearsSmallMediumLargeIn your own words, please describe what you hope to accomplish and how you believe yourlife will change by losing weight.Patient History QuestionnaireHonorHealth Bariatric CenterPage 14 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)Dietary HistoryApproximate age when you first seriously dieted.List any physician-supervised and documented weight loss attempts.List the diets and diet programs you have tried:Date(s)Jenny CraigNutri-SystemWeight WatchersOpti/Medi FastAtkinsOther:Other:Duration Yes No Yes No Yes No Yes No Yes No Yes No Yes NoMD Supervised(circle one) Yes No Yes No Yes No Yes No Yes No Yes No Yes NoMaxLossMD Supervised(circle one) Yes NoMaxLossList the Medications and Treatments you have tried:Date(s)Fen/Phen/Redux Yes NoMeridia Yes NoDuration Yes NoTopamax/Topiramate Yes NoBontril/Phendimetrazine Yes No Yes NoAlli/Xenical Yes NoHcG Yes No Yes No Yes No Yes No(Circle one) Shots or OralOther:Other:Acupuncture Yes No Yes No Yes No Yes No Yes No Yes NoExerciseIf you are able to exercise, what kinds of exercise do you do?Type of ExerciseDuration (how long each time) Frequency (times per week)Patient History QuestionnaireHonorHealth Bariatric CenterPage 15 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)Initial Nutrition AssessmentPlease fill out the following information for your appointment with the wellnesscoach/dietitian. Answer the questions based on the past month of eating habits.Please check the circle that describes your weight over the past 6 monthso I’ve gained weight (If so how much? )o I’ve lost weight (If so how much? )o My weight hasn’t changedPlease place a check in the column below that best describes how often you eat thefollowing foods:FOODDaily2-3 x1xMonthlyLess than Dislike/NeverweekweekmonthlyMeat ce CreamCrackersChipsFried FoodsFast FoodsSodaCoffeeJuice/ GatoradeEnergy DrinksPlease check the circle that describes your daily water intakeo I drink more than 64 oz of watero I drink 32-64oz of watero I drink less than 32 oz of waterPlease check the circle that describes how manytimes you eat meals per dayo 4 or moreo 2-3othan 4o More2 or lesso 2-3Patient History QuestionnaireHonorHealth Bariatric CenterAre you currently taking a dailymultivitamin supplement?o Yeso NoPlease check the circle that describes howmany times you eat snacks per dayo 4 or moreo 2-3o 2 or lessPage 16 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)System ReviewPlease check all symptoms that you currently have. Write in any additional problems.Head, Eye, Ear, Nose, and Throat No Complaints Vertigo headache sinus problems Pain in/around ears nasal congestion double vision Dizziness nasal drainage lump in throat Rhinitis hoarseness ringing in ears Sore throat blurred vision hearing loss Uvulectomy buzzing in ears pain with swallowingRespiratory cough asthma wheezing bronchitis emphysema use two pillowsCardiovascular balance disturbances decreased night vision dysphasia ear drainage visual aura No Complaints blood in sputum wake up at night short of breath out of breath with exertion wake up at night coughing or choking shortness of breath at night No Complaints cold feet blue toes blue finger palpitations pain in legs heart attack heart murmur squeezing of chest pain in neck loss of pulses skipping of heartbeat pains in arms pounding of heart high blood pressure pains in chest irregular heartbeat abnormal electrocardiogram Gastrointestinal colitis cramps nausea fissures diarrhea No Complaints vomiting irritable colon heartburn acid stomach gassiness blood in stools constipation burning in throat hemorrhoids pains in stomach burning in stomach food sticking in chest belching fluid in throat pain with bowel movement Genitourinary No Complaints nephritis kidney stones pain with urination trouble stopping urine blood in urine bladder stones small urine stream urinary tract infections kidney failure frequent urination trouble starting urine leakage of urine with cough or sneeze Men loss of erection No Complaints painful erection discharge from penisPatient History QuestionnaireHonorHealth Bariatric CenterPage 17 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)Women No Complaints irregular periods vaginal bleeding vaginal discharge pain with intercourse Endocrine (Glandular) No Complaints goiter hyperthyroid grave’s disease adrenal gland tumor diabetes x-ray to thyroid frequent flushing frequent heavy sweating low thyroid thyroid nodules Musculoskeletal flatfeet sprains arthritis sciatica hip pain No Complaints foot pain slipped disk broken bones knee pain fluid in joints herniated disk ankle pain pain in joints swelling of joints warm joints low back pain redness of skin over joints Neurological No Complaints fits fainting convulsions twitching of muscles tremor dizziness falling at night loss of consciousness vertigo shakiness falling to the side pins & needles feelings tingling numbness weakness of grip weakness of any muscles Psychological No Complaints major depression (once) drug abuse/dependencyWhen? psychotic disorder major depression (twice or more) anorexiaWhen? bulimia posttraumatic stress disorder generalized anxiety disorder borderline personality disorder panic disorder schizophrenia panic attacks bipolar disorder obsessive compulsive disorder manic depression inpatient hospitalization dissociative disorderwhen: dissociative identity disordercondition: multiple personality disorder psychotherapy alcohol abuse/dependencywhen:condition:Patient History QuestionnaireHonorHealth Bariatric CenterPage 18 of 23Rev. 04/2019
HonorHealth Bariatric Center(The patient completes all informationrequested except when indicated.)Patient NameHonorHealth Bariatric CenterDiagnostic QuestionnaireThe following questions are to help us determine a well suited program for your success. Please answerquestions accurately to the best of your ability.1. Are you normally a large-volume eater at mealtimes?YesNo2. In a typical week, how frequently do you engage in unplanned snacking?Many times per dayOnce per day3-6 times per week1-2 times per weekNever3. In a typical month, how frequently do you respond to stress or emotions (sadness, boredom,anger, etc.) by eating or snacking?DailyA few times per weekA few times per monthLess than monthly4. Name the triggers or sources of stress that may cause inappropriate eating., , ,5. Name your top three favorite foods.a. , b. , c.6. Do you regularly eat after 7:00 p.m.?YesNo7. Do you typically consider yourself well-disciplined and focused?YesNo8. Have you achieved weight loss through dieting & exercise in the past?YesNoa. If so, what was your maximum weight loss?poundsb. How long did it take to achieve?monthsc. How long did you maintain it prior to regaining weight?months9. Do you have either diabetes or insulin resistance?YesNo10. Can you refrain from drinking alcohol?YesNo11. In which bariatric services are you interested? Medical Weight Loss Program Adjustable Gastric Band Lap Gastric BypassPatient History QuestionnaireHonorHealth Bariatric Center Revision Sleeve Other:Page 19 of 23Rev. 04/2019
HonorHealth Bariatric CenterPatient Name(The patient completes all informationrequested except when indicated.)(INSERT LETTERHEAD HERE)(Date)HonorHealth Bariatric Center10210 N. 92nd St. #101Scottsdale, AZ 85258Re: (insert patient name)DOB: (insert the patient’s date of birth)Letter of Medical Necessity(For patients with Medicare or Medicare Advantage plans, a Letter of Medical Clearance or Surgical RiskAssessment must be submitted to obtain authorization for Bariatric Surgery)To whom it may concern:(Patient name) is a (age) year-old male/female with a current weight of (weight) and a BMI of (BMI).He/She has suffered from obesity for the past (# of years) years. He/She has the following co-morbidconditions: (insert co-morbidities and any treatments being used). He/She has tried many diets in thepast including: (insert any formal weight loss programs the patient has tried including diets, medication,behavior modifications, and exercise programs).I recommend bariatric surgery be performed at HonorHealth Bariatric Center, which is a Metabolic andBariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) AccreditedComprehensive Center with Adolescents.Sincerely,(Signature)Patient History QuestionnaireHonorHealth Bariatric CenterPage 20 of 23Rev. 04/2019
Self-Pay PricingAdditional Procedure(s) Only if Deemed M
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:
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 .
rates after bariatric surgery have fallen by 80% in the past decade. Data involving nearly 60,000 bariatric pa-tients from American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Centers of Excellence data-base show that the risk of death within the 30 days fol-lowing bariatric surgery av-erages 0.13%, or approxi-
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
18404 N Tatum #101 Phoenix, AZ 85032 (602) 992-1900 JCL ACO Stacy Gustin, DO HonorHealth Medical Group - Arcadia 100 4840 E. Indian School Rd., Ste. 100 Phoenix, AZ 85018 (480) 882-7360 SHP Nasser Hajaig, MD HonorHealth Medical Group - West Bell Road 6206 W Bell Rd, Suite 5 Glen
VOLUNTEER SERVICES CORPORATE OFFICE Network Director: Liz Hyatt 8283 N. Hayden Road Suite 275 Phone: 480-587-5097 Scottsdale, AZ 85258 E-mail: Liz.Hyatt@HonorHealth.com Email: volunteers@honorhealth.com DEER VALLEY CAMPUS VOLUNTEER SERVICES Supervisor: Kylene Price 19829 N. 27th Avenue Phone: 623-879-5766
Post-bariatric surgery health behaviour changes. Post-bariatric surgery diet. Centres that perform bariatric surgery will typically provide pa-tients with a dietary protocol to follow. Initially, over several weeks, patients transition from liquid, to soft and then to a sol-id diet. Over the long term, patients are encouraged to follow
Bellevue Bariatric Program February 2019 Lactose Intolerance and Sensitivity after Bariatric Surgery by Kat Cozza , PA-C Patients who have had bariatric surgery may experience a varie-ty of gastrointestinal changes. In particular, some bariatric by- pass patients may experience GI symptoms due to an intoler-ance or sensitivity to lactose found .
Literacy development lies at the heart of the Grade 1–8 language curriculum. Literacy learning is a communal project and the teaching of literacy skills is embedded across the curriculum; however, it is the language curriculum that is dedicated to instruction in the areas of knowledge and skills – listening and speaking, reading, writing, and viewing and representing – on which literacy .
