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:
Select
Alma
Dra. Alex
Eduardo
Preferred Surgeon
Dr. Martin Orduño
Dr Luis Cazares
Dr. JP Fernández
Surgery of interest:
Select
Gastric Sleeve
Single Incision Sleeve
Gastric Plication
Bypass
Mini Bypass
Band
Duodenal Switch
SADI-S
Gastric balloon
Gastric balloon removal
Plastics
Revision band to Sleeve
Revision band to bypass
Revision band to mini bypass
Revision band to Duodenal Switch
Band Removal
Revision Sleeve to Sleeve
Revision Sleeve to bypass
Revision Sleeve to mini bypass
Revision Sleeve to DS
Revision Sleeve to SADI-S
Revision mini bypass to bypass
Revision bypass to bypass
Revision bypass to DS
Revision band over bypass
Revision Plication to sleeve
Revision Plication to bypass
Additional procedure request along with your WLS:
Select
Gallbladder
Hiatal Hernia Repair
Hernia Repair
Gallbladder and Hiatal Hernia Repair
Other
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 :*
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territory
Nova Scotia
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Select City
Other
List states
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 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
Laparoscopic
Open Incision Surgery
Date:
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
Current Age or at death
Cause of Death
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
List medications:*
High Triglycerides:*
Yes
No
List medications:*
Diabetes:*
Yes
No
List medications:*
As a result of your diabetes, Do you have:
Neuropathy:*
Yes
No
Nephropathy (kidney problems):*
Yes
No
Asthma:*
Yes
No
List medications:*
As a result of your asthma, in the past 2 years, have you:
Visited the ER:*
Yes
No
Been hospitalized?:*
Yes
No
Been prescribed steroids?:*
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
Diagnosed with Hernia:*
Yes
No
Surgery to repair hernia:*
Yes
No
Laparoscopic
Open
Gallbladder Disease:*
Yes
No
Gallbladder removed:*
Yes
No
Laparoscopic
Open
GERD:*
Yes
No
BONE OR JOINT PROBLEM:
Hips*
Yes
No
Knees*
Yes
No
Ankles*
Yes
No
Feet*
Yes
No
Back*
Yes
No
Have you seen a specialty doctor for these problems?
List any weight related injuries or trauma:
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
How are they being treated?:
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
Frequency (cigarettes per day):*
Date of last cigarrette:*
When did you start:*
Previous smoker?:*
Yes
No
Quit date:*
Do you ever drink alcohol?:*
Yes
No
When did you start:*
How often:*
Number of drinks each time:*
Are others concerned about your alcohol use?:*
Yes
No
Ilicit drug use?:*
Yes
No
Type of drug used:
Frequency:
Do you use caffeine (Coffee, cola, chocolate, No-Doz, Aqua Ban)?:*
Yes
No
Type:*
Cups/Day:*
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.
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