Patient Intake Questionnaire

 

Please complete forms prior to attending an information session.

 

Patient Name
First Name:*
 
Last Name:*
 
Primary Phone Number:*
 
Date of Birth
(mm/dd/yyyy):*
 
 
Weight(lb):*
Height:*
ft   in

* To qualify, your Body Mass Index (BMI) should be 40 or greater. If your BMI is between 35-40, then you must have at least one significant co-morbidity (serious medical problem). Individuals with a BMI of 30-35 with at least one significant co-morbidity quality for the LAP-BAND© Adjustable Gastric Banding System. Those with BMI 10+ 30-40 qualify for the intragastric balloon and vBloc procedure.

 

Please enter the information below to begin the registration process:

 
Please provide information about your dieting history. This information is crucial to obtaining insurance coverage. Please provide as much detail as possible.
Dieting History









 
For the following questions, please check the correct answer
Endocrine/Metabolism
Diabetes Mellitus
 





 
Have you ever been diagnosed with thyroid disorder?
 
 
Do you have high cholesterol?
 






 
Gout?
 






 
General Health Status
Functional Health Status
 



 
Difficulty Walking
 



 
Pulmonary
Are you oxygen dependent?
 
Do you have a history of severe COPD?
 
Do you have a history of pulmonary embolism?
 
 
Asthma
 





 
Obstructive Sleep Apnea
 





Gastrointestinal
Do you have heartburn or esophageal reflux that requires medication?
 





 
Do you suffer from ulcers in your stomach or intestines?
 
Have you had any blood per rectum recently?
 
 
Gallstones or gallbladder disease?
 





 
Fatty Liver Disease
 





 
Have you ever vomited blood?
 
 
Abdominal Hernia
 





 
Do you have Crohn's disease?
 
Have you ever been diagnoses with irritable bowel syndrome?
 
Musculoskeletal
Arthritis (degenerative joint disease)
 





 
Do you suffer from arthritis in your hips?
 
Do you suffer from arthritis in your knees?
 
Do you have rheumatoid arthritis?
 
Have you ever been treated with steroids for your arthritis?
 
 
Do you suffer from back pain?
 





 
Fibromyalgia
 





Cardiovascular
Have you been diagnosed with high blood pressure?
 





 
Do you have difficulty sleeping or breathing while laying flat on your back?
 
 
Lower Extremity Swelling
 




 
Do you have venous stasis disease?
 
 
DVT or Pulmonary Embolism
 





 
Ischemic Heart Disease
 





 
Do you suffer from congestive heart failure?
 




 
History of chest pain?
 





 
Do you have a pacemaker or defibrillator?
 
Have you had a cardiac stent or balloon angioplasty?
 
 
Do you have sickle cell?
 


Renal
Have you been diagnosed with renal insufficiency?
 
Are you currently requiring or on dialysis?
 
Stress urinary incontinence?
 
Nutritional/Immune/Oncology/Other
Do you have Hepatitis A?
 
Do you have Hepatitis B?
 
Do you have Hepatitis C?
 
Do you have HIV/AIDS?
 
Have you ever been diagnosed with Cancer?
 
Have you ever had to use Steroids/Immunosuppressants for a chronic condition?
 
Have you ever had to use therapeutic anticoagulation?
 
Do you have PCOS?
 
Do you have multiple sclerosis?
 
Social History
Please select the answer that best describes you
Tobacco:
 





 
Alcohol Consumption:
 


 
Drug Use:
 



Preoperative Questions
How long have you thought about surgical options for your weight loss? *
 
 
How long have you struggled with obesity? *
 
 
What is your highest weight? *
 
 
Has anyone in your family had bariatric surgery?


 
Which surgical procedure are you interested in (check all that apply):



 
How did you hear about our program?



 
Name of referring physician: *
 
 
Primary Care Physician Information:
 
Physician Name:*
 
 
Address 1: *
 
 
Address 2:
 
City:*
 
 
State: *
 
 
Zip Code: *
 
 
Phone: *
 
 
Fax:
 
Are you a Jehovah’s Witness? *
 
 
Please list all the medications you are currently taking and the dosage: *
 
 
Do you have any drug allergies? *
 
 
Previous Surgical Procedures
Please check all that apply & list date of surgery
Appendectomy – open  
Appendectomy – Lap  
Bariatric Surgery – Adjustable Gastric Band  
Bariatric Surgery – Sleeve  
Bariatric Surgery – Roux-en-Y Gastric Bypass  
Bariatric Surgery –Loop Gastric Bypass  
Bladder Sling  
Breast Augmentation  
Breast Reduction  
C-Section  
Carpal Tunnel  
Cholecystectomy (gallbladder removal) – open  
Cholecystectomy (gallbladder removal) – laparoscopic  
D&C  
Hysterectomy – open  
Hysterectomy – vaginal  
Inguinal Hernia Repair  
Incisional Hernia Repair  
Kidney Stone Removal  
Lasik Eye Surgery  
Partial Colectomy  
Tonsillectomy  
Tubal Ligation  
Umbilical Hernia Repair  
None
Other
 
Family History
Mother
Weight:
Deceased?
 
Father
Deceased?
 
Are there any other family members with relevant history?
 
Employment Status




 
 
Pharmacy Information
 
Insurance Information
Do you have insurance?
 
 
 
 
Attention Bariatric Preoperative Patients…

It is essential that you are aware that ANY WEIGHT GAIN since your attended information session may result in the postponement of your surgery.

Gaining weight during this process greatly decreases the chances that your surgery can be performed as a laparoscopic procedure. It also significantly increases your risks for developing intra-operative and postoperative complications, including but not limited to blood clots and cardiac and respiratory issues, even death.

Our bariatric program focuses on your preoperative and postoperative good health as our first priority.


 
 
Anticipated Out-Of-Pocket Expenses

Deductibles, Co-Payments and Non-Covered Services

You will be responsible for any deductibles, co-payments or other non-covered services as required by your insurance provider. This could include a pre-surgery payment required for patients undergoing a weight-loss surgical procedure. For assistance in estimating the costs that will be due prior to your date of surgery, please contact our office at (843)958-2590.

In addition, we encourage you to contact your insurance company or you employee benefits representative to inquire about any “exclusions to weight-loss surgery” that may exist in your policy, as well as any criteria that must be met prior to surgery.


Acknowledgement

I acknowledge that there are certain out-of-pocket costs for which I will be responsible for before my request for surgery will be processed.  

 
Release for Use of Photography

I do hereby authorize the staff of RSF Bariatric and Metabolic Services absolute permission to utilize any photographs taken of me pre-operatively, intra-operatively or post-operatively in reference to my Roux en-Y Gastric Bypass, Gastric Sleeve or Laparoscopic Adjustable Gastric Band, to use, re-use, publish or republish in whole or in part, individually or in conjunction with others, in any medium and for any purpose whatsoever, including (not limited to) illustration, promotion, and/or advertising and trade.

I also release and discharge RSF Bariatric and Metabolic Services from any and all claims and demands arising from or in connection with the use of my photographs, including claims for libel.


I have read and fully understand the intent and purpose of this release and am signing it without reservation.  
 
I agree that the information given on this questionnaire is true based on my current knowledge.   
 
 
 



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