Medical History Form - Bariatric/Obesity Surgery

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Medical History Form - Bariatric/Obesity Surgery

Thank you for visiting the Med Access web site.

Med Access will forward your medical details to your selected surgeon who will reply with his basic clinical evaluation and any relevant details as soon as possible.

Name

Mailing Address

Gender

Male Female

Martial Status

Age

Height in cms

Weight in Kgs

BMI

City

State

Country

Telephone

Mobile

E-mail

Please indicate your weight at the following times. Please indicate whether you consider your weight was below average, average, above average or very heavy in the relevant boxes.

Weight at beginning of high school	:
Weight at commencing work (21 years)	:
Weight at time of marriage (if applicable)	:
Age when you first remember overweight	:
Age when you first began dieting	:
At what weight have you felt your best	:

Dieting History

Diet Program if any and the result

Food History
Preferred foods (foods most likely to make you go off a diet)
(Rank each selection from 1- like very much to 4-Don't care )

Soda / Soft Drinks	:
Cookies	:
Pizza	:
Cakes / Pies	:
Salad Dressings	:
Fried Foods	:
Chips / Snacks	:
Pasta	:
French Fries	:
Chocolate	:
Potatoes	:
Candy	:
Steaks / Chops	:
Others (Specify)	:

Favorite Foods

How do you decide when to stop eating?

Food Allergies (if any)	:
Do you drink juices, sweet tea, sweets or regular sodas	:
Do you understand the long-term changes in food intake that will be necessary after surgery for the rest of your life?	:
How many meals you eat in a day	:
Do you eat between meals	:
Do you drink for reasons other than hunger or thirst	:
Do you drink milk	:
Do you drink water How much a Day?	:
Do you eat sweets If yes How often	:
Do you understand the long term changes in food intake that will be necessary after surgery for the rest of your life	:
Do you understand the consequences of not complying with post op food guidelines	:
How many meals you eat in a day Do you eat between meals	:
How fast do you eat	:

WEIGHT RELATED ILLNESS

Have you had, or do you have, any of the following illnesses or symptoms?
Heart Disease	:
High Blood Pressure	:

Do you have or ever had any of the following illness - If Yes Year Diagnosed
Angina	:
M.I(myocardial infarction)	:
CABG(coronary artery bypass graft)	:
High Cholesterol	:
Medication list	:
Diabetes	:
Neuropathy	:
Abnormal EKG	:
Stress test to rule out cardiac problems	:
High Triglycerides	:
Asthma	:
Trouble sleeping	:
Shortness of Breath	:
Last fasting blood sugar	:
Morning Headaches	:
Daytime drowsiness	:
Restless Sleep	:
Snoring	:
Awakening at night	:
Observed apneas	:
Sleep apnea syndrome	:
Last sleep study, CPAP used	:
Heartburn/hiatus Hernia	:
Hepatitis	:
Blood Transfusion	:
AIDS/HIV exposure	:
Colitis	:
Kidney Disease	:
Bleeding Abnormality	:
Thyroid problems	:
Gall bladder disease	:
Low back strain/pain/sciatica	:
Pain in hips/knees/ankles/feet	:
Leakage of urine with laughing/coughing/sneezing	:
Leg ulcers, scaly & thick skin if yes do you have Edema	:

Only Female patients
Are you pregnant now	:
Number of pregnancies	:
Number of live births	:
Obstetric complications	:
Age at first period	:
Date of last period	:
Miscarriages/Abortion	:

Please list below all serious and hospitalization you have experienced in adulthood: Major Illness /Surgery Date and Treatment. If Yes, Please list medication and reaction.	:

SOCIAL HISTORY

Do you use tobacco currently If yes, how many packs/day	:
How many years have you smoked	:
Have you tried to quit	:
Did you smoke in the past	:
How many packs/day	:
When did you quit	:
Do you drink beer,liquor,or wine	:
How many glasses per week	:
Do you use any recreational drugs	:
Which one(s)	:
Have you ever had an addiction to drugs	:
Who usually prepares the food you eat at home	:

ACTIVITY LEVEL & SOCIAL INFO

What exercise do you do on regular basis	:
How many sessions of exercise (walking,sports,etc)do you do per week for more than 30 minutes at a time	:

EDUCATION

Highest level of course pursued

Please list your activities (out of home)	:
Please list major personal interests	:
How would you describe your current weight	:
How does your weight affect you in daily activities	:
How does your weight affect you socially	:
Why do you want to lose weight	:
Why are you considering surgery to help you lose weight	:
How much weight would you like to lose	:
Highest acceptable weight	:
Desired lowest weight	:
How does your family feel about you having this surgery	:
What are your concerns about your health	:
What are your concerns or fears about the surgery	:
What surgical procedure are you currently interested in	:

PATIENT COMMITMENT

IF YOU ARE ACCEPTED FOR SURGERY, THE FOLLOWING ARE VERY IMPORTANT TO MAINTAIN GOOD HEALTH AND TO ACHIEVE THE DESIRED WEIGHT LOSS.
Are you willing to avoid foods and beverages containing sugar	:
Are you willing to never use tobacco products	:
Please Confirm Alcohol causes gastric irritation and liver damage. After surgery, frequent alcohol consumption is unwise and can be harmful. Are you willing to have no alcohol for at least one year after surgery, and to use alcohol only on a very limited basis thereafter	:
Please Confirm Are you willing to make a commitment for regular lifelong medical follow-up	:

You're all set. Thanks for completing the form

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