October 18, 2016

Health Questionnaire

Click here to register and then return to this page and login.

When you are logged in, the “SAVE” button at the bottom of this form will be displayed and your name will display in the top right corner. This allows you to save and return later to complete the health questionnaire.

Log in screen will remain visible after login. It is imperative that you give honest information. This helps us to provide the best care and treatment. After completing this form, click the “submit” button at the bottom.

Name:*
Address:*
Email:
Cell phone:*
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Home phone:
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Emergency Contact:*
Emergency contact number:*
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If you were referred by someone, tell us their name and phone number.
Their phone:
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If you were not referred, how did you find us?

Your gender:*
Type of surgery desired.
Date of birth:*
Age:*
Desired surgery date:*
Occupation:*
Height:*
Weight:*
BMI:*
Have you previously had weight loss surgery?*
If yes, what type of surgery, when, and where did you have the surgery.
If yes, how much weight did you lose from the surgery, how much did you regain, over what period of time?
Marital status:*
Do you have any alergies?*
If yes, list and give details of allergies.
Primary health care provider name and phone number:
List any major illnesses. Specify date ranges, treatments, and outcome.
List all other surgeries; dates, types, and reasons.
List all medications you are currently taking. Include vitamins, herbal supplements, and over the counter meds. Specify dosage, frequency, purpose, and date started.*
List all immediate genetic family members. Identify each one as obese (yes or no), and other health issues.*
List other genetic family members who are obese. Specify relation and identify each for mother's or father's side.*
Family history of cancer?*
If yes, specify relation to you and type.
Family history of diabetes?*
If yes, specify relation to you and type one or type two.
Family history of heart attack?*
If yes, specify relation to you.
Family history of stroke?*
If yes, specify the relation to you.
Family history of high blood pressure.*
If yes, what is the relation to you?
Do you experience shortness of breath during physical activity?*
Do you exercise regularly?*
If yes, how often and long?
Do you have or have you had asthma?*
Do you experience swelling of the ankles?*
If yes, for how long, what you do to decrease swelling, what do you take for the pain.
Do you have thyroid problems?*
Are you diabetic?*
If yes, for how long and what medications are you taking?
Do you monitor your blood surgar?*
If yes, how often?
Have you been diagnosed with PCOS?*
Do you have high blood pressure*
If yes, for how long and what medications are you taking to treat high blood pressure?
Do you experience chest pain?*
If yes, how often and for how long?
Do you have any history of heart disease?*
If yes, give details.
Have you had a heart attack?*
If yes, how long ago?
Have you been diagnosed with fatty liver, cirrhosis hepatitis, or any liver disease?*
If yes, explain details.
Have you been diagnosed with rheumatoid arthritis?*
Are you taking or have you taken nonsteroidal anti-inflammatory drugs (NSAID's) for joint paint?*
Have you been diagnosed for lupus?*
Have you been diagnosed as HIV positive?*
Have you been diagnosed with diverticulitis?*
Do you have any history of ulcers?*
Have you been diagnosed with crohn's disease or ulcerative colitis?*
Do you have indigestion or heart burn?*
If yes, for how long?
List any foods or drinks that cause digestive problems. Specify the result of each item.
Do you ever have any type of pain in the abdomen?*
If yes, give details (sharp, dull, hot, cold, aching, crushing, etc).
Any changes in bowel movements?*
Any bloody stools?*
Any history of hemorrhoids?*
Have you ever been treated for an eating disorder?*
Are you generally happy with your life other than your weight?*
Do you have a history of depression?*
Have you used tobacco products in the past?*
Do you use tobacco products now?*
If yes, specify how often, types used, and for how long.
Do you drink alcohol?*
If yes, specify what beverages and frequency.
Do you consume products with caffeine (coffee, cola, chocolate, No-Doz, Aqua Ban, energy drinks)?*
If yes, specify what products and frequency.

Do you experience any of the following joint conditions?

Ankles:
Knees:
Hips:
Back:
Other:
Explain any treatments and medications for joint problems and injuries.
Have you ever been told you have degenerative changes or early arthritic changes in your joints?*
Do you have any family history of arthritis or back trouble?*
How long have you been overweight?*
What things have you done to try to lose weight (such as diets, exercise programs, etc)?*
Have you taken diet pills?*
If yes, list what types and for how long you used the product.
Check any of the following diet programs that you have tried.*
How much weight did you lose and/or regain with each program. Specify time frame.
Are you a snacker?*
Are you a volume eater?*
Do you eat a lot of sweets?*
How often do you eat sweets?
Do you frequently eat fast food?*
Do you drink carbonated beverages?*

Are you experiencing any of the following conditions?

Frequent or severe fatigue?*
Frequent or severe weakness?*
Fever, chills, or night sweats?*
Frequent or severe headaches?*
History of head injury with loss of consciousness?*
Hearing problems?*
Ear pain?*
Nasal congestion?*
Chronic sinus congestion?*
Frequent bloody nose?*
Dental problems?*
Wear dentures?*
Sores in mouth?*
Wheezing?*
Coughing?*
Breast lump, pain, or discharge?*
Heart murmur?*
Chest pain with exercise or activity?*
Any untreated STD's?*
Using birth control?*
Infertility?*
Anemia?*
Any previous blood transfusions?*
Bleeding tendency?*
Convulsions or seizures?*
Paralysis?*
Numbness or tingling?*
Memory loss?*
Anxiety?*
Mood swings?*
Sleep problems?*
Drug or alcohol abuse?*
Hay fever?*
Please list any additional information that may assist in your health planning.

I understand that full disclosure is necessary to my medical safety. I have completed this health questionnaire to the best of my knowledge. I have answered these questions with complete honesty to insure my health and safety.

Patient Signature:
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