Health History Form
The information you provide will help us plan your treatment.

PATIENT INFORMATION:

If you are working with a coordinator, please select her/his name:

Preferred Surgeon

Dr. JP Fernández Dr Luis Cazares Dr. Martin Orduño

Surgery of interest:

Additional procedure request along with your WLS:

First Name:*

Last Name:*

Gender:*

Male Female

Date of birth*

WHAT IS YOUR PROSPECTIVE SURGERY DATE?*
(Date not guaranteed until your coordinator confirms.)

Were you referred, by whom?:*

Occupation:

Address:*

State, City :*

Other

Zip Code:*

E-mail address:*

Home Phone# :*

Cell Phone#:

Work Phone#:

PRIMARY HEALTH CARE PROVIDER:

Name of Primary Health Care Provider:

How long has he/she treated you?:

Conditions treated?:

If you are also under the care of other physicians, please provide details and conditions treated

PLEASE PROVIDE EMERGENCY CONTACT INFO:

Name Emergency Contact:*

Phone# of emergency contact:*

Cell# of emergency contact:

Blood Type:

Last CBC-Hemoglobine:

Your Measurements

Age:*

Height:*

Ft:

In:

Weight (lb):*

BMI:*

Carry Excess Weight on*:

Torso Hips & Thighs

MEDICAL INFORMATION:

ALLERGIES:

Allergic to any medication?:*

Yes No

List each medication and your reaction:*

Are you allergic to any type of Tape?:*

Yes No

Are you allergic to latex?:*

Yes No

Are you allergic to Iodine?:*

Yes No

Allergic to any food?:*

Yes No

Are you allergic to other?:*

Yes No

CURRENT MEDICATION (INCLUDE VITAMINS, HERBAL SUPPLEMENTS, OVER-THE COUNTER MEDICATION, ETC):
Note: Pl. fill the below fields using commas separations as shown below

Name of medication	Dose	How often taken	Purpose	When use started	Check the appropriate box
					Required As needed
					Required As needed
					Required As needed
					Required As needed
					Required As needed
					Required As needed
					Required As needed
					Required As needed

*IMPORTANT TO WOMEN
The time required to qualify for bariatric surgery must be at least 9 months from your last pregnancy, childbirth, cesarean section, or abortion.
If you are using a birth control that contains hormones, you should stop it for at least one or two months before your bariatric procedure and three months after your procedure and go to your gynecologist for the adjustment of hormone treatment, as it increases the risk of blood clots blood.

Have you ever taken or are you currently taking blood thinners? If yes, what for and how long? :*

Yes No

Are you taking any medications that have aspirin in them?:*

Yes No

Are you taking any non-steroidal anti-inflammatory drugs (ibuprofen/Aleve/Advil/Celebrex/Motrin/Toradol)?:*

Yes No

LIST OF ANY MAJOR ILLNESSES:

Please identify the following Childhood illnesses that you have had:
Measles	Mumps	Chickenpox
Obesity	Heart murmur	Rheumatic Fever

Please identify which of the following serious illnesses you have been diagnosed with:
Hepatitis	AIDS/HIV - any infectious diseases	Colitis
Kidney Disease	Bleeding Disorder	Thyroid disorder
Irritable Bowel	Rheumatoid Arthritis	Multiple Sclerosis
Blood Clot / Thrombosis	Sickle Cell Disease	Fibromyalgia
Heart problems	Endocrionological disorders	Anemia

Illness	Date	Treatment	Outcome

*If additional illnesses, please use comment box at bottom of page

LIST ALL SURGERIES YOU HAVE EVER HAD:

Surgery	Date	Reason

Have you ever had surgery to aid in weight loss?:*

Yes No

FAMILY HISTORY:
Note: Pl. fill the below fields using commas separations as shown below

Please indicate if there is a family history of:
Obesity	Kidney Disease	Lung Disease, asthma, emphysema	Diabetes
High Blood Pressure	Bleeding tendency or blood disorder	Heart Disease	Breast Cancer
High Cholesterol	Blood Clot	Colon Cancer	Pulmonary Emboli (blood clot to lung)
Sickle Cell Disease	Infectious Diseases

Family member	Living	Health Problems
Mother*	Yes No	Yes No
Father*	Yes No	Yes No
	Yes No	Yes No
	Yes No	Yes No

Weight Related Illnesses
Have you had, or do you have any of the following illnesses or symptoms?

Heart Disease	Yes No	Diagnosis Year
Angina*	Yes No
M.I. (myocardial infarct)*	Yes No
Any cardiovascular disease*	Yes No
Abnormal EKG*	Yes No
Stress Test*	Yes No
Arrhythmia*	Yes No
High Blood Pressure*	Yes No
	Yes No

High Cholesterol:*

Yes No

High Triglycerides:*

Yes No

Diabetes:*

Yes No

RESPIRATORY SYSTEM:

Do you experience shortness of breath with physical activity?:*

Yes No

Do you exercise regularly?:*

Yes No

Other lung/ breathing problems:*

Yes No

OTHERS:

Sleep Apnea:*

Yes No

CPAP/BI-PAP used regularly:*

Yes No

Gallbladder Disease:*

Yes No

GERD:*

Yes No

Circulation:

Circulation Problems:*

Yes No

Bleeding Tendency:*

Yes No

Chronic Venous Inssufficiency:*

Yes No

Edema(swelling):*

Yes No

Thick scaly skin:*

Yes No

Varicose Veins:*

Yes No

Leg ulcers:*

Yes No

Currently healed?:*

Yes No

Thrombosis of any kind:*

Yes No

MENTAL HEALTH:

Have you ever been treated for an eating disorder?:*

Yes No

Are you generally happy with your life other than your weight?:*

Yes No

Do you have a history of depression?:*

Yes No

Diagnosed with any mental health disorder?:*

Yes No

TOBACCO/ALCOHOL USAGE:

Do you use any form of tobacco? (smoke/chew):*

Yes No

Do you ever drink alcohol?:*

Yes No

Ilicit drug use?:*

Yes No

Do you use caffeine (Coffee, cola, chocolate, No-Doz, Aqua Ban)?:*

Yes No

Hobbies:

What is you greatest fear or expectation regarding having surgery?:

Now that you have completed our history form please take a moment to look it over one last time to assure that all questions have been answered completely.
It is very important that we help you prepare for surgery. Once you are sure that all question are answered, please submit the form.
Please enter your full name to verify that all the information you have provided is accurate to the best of your knowledge.

Comments

Please read and sign the following authorization:

I , authorize Dr. JP Fernández, Dr Luis Cazares, Dr. Martin Orduño and/or his designees to request medical information, if required, from any of the physicians that I have listed above, as a part of this health history questionnaire. The information that is to be requested from the physicians may include but is not limited to, History and physical exams, Discharge summaries, Consultation reports, Laboratory and image studies.

I certify that my health history information is true and correct and that I am not intentionally falsifying my health information or misleading in any way about my current health including intentionally leaving out health information. I further understand that any false statements regarding my medical history could result in cancellation of surgery and I would be responsible for all cost incurred by .

Name:*

Date:*

Your security and privacy are our top priority, as you can read on the privacy policy on our website. Therefore, your information will not be sold and only released on a strictly need-to-know basis within our membered company. Still, if you want your information to be HIPPA compliant, please click here and fill it out . When you are finished click on the choose file button to be sent to us . Hand writing or digital signatures are accepted.

HIPPA form:

Hips*	Yes No	Knees*	Yes No
Ankles*	Yes No	Feet*	Yes No
Back*	Yes No

Health History FormThe information you provide will help us plan your treatment.

PATIENT INFORMATION:

PRIMARY HEALTH CARE PROVIDER:

PLEASE PROVIDE EMERGENCY CONTACT INFO:

MEDICAL INFORMATION:

ALLERGIES:

CURRENT MEDICATION (INCLUDE VITAMINS, HERBAL SUPPLEMENTS, OVER-THE COUNTER MEDICATION, ETC): Note: Pl. fill the below fields using commas separations as shown below

LIST OF ANY MAJOR ILLNESSES:

LIST ALL SURGERIES YOU HAVE EVER HAD:

FAMILY HISTORY: Note: Pl. fill the below fields using commas separations as shown below

Weight Related Illnesses Have you had, or do you have any of the following illnesses or symptoms?

RESPIRATORY SYSTEM:

OTHERS:

BONE OR JOINT PROBLEM:

Circulation:

MENTAL HEALTH:

TOBACCO/ALCOHOL USAGE:

Health History Form
The information you provide will help us plan your treatment.

CURRENT MEDICATION (INCLUDE VITAMINS, HERBAL SUPPLEMENTS, OVER-THE COUNTER MEDICATION, ETC):
Note: Pl. fill the below fields using commas separations as shown below

FAMILY HISTORY:
Note: Pl. fill the below fields using commas separations as shown below

Weight Related Illnesses
Have you had, or do you have any of the following illnesses or symptoms?