Premier Metabolic and Bariatric Associates Registration -1Office use only consult visit info>>>

Procedure choice:

Height :

Weight:

BMI:

Name: ____________________________ _______________________ Date of Birth: _____________ Last (please print) First ________________________________________________________________________________________________________

Which one of our Physician’s would you like to perform your surgery?: ___ Dr. C. Joe Northup ___ Dr. Mujeeb U. Siddiqui Your current height: ________

Your estimated current weight: ___________

*Have you ever had weight loss surgery before: Yes

No (circle one) Type: ______________________

Procedure Choice: (this does not lock in your choice; this can be changed at your consultation) ___ Gastric Bypass (Roux en Y) ___ Duodenal Switch (BPD/DS) ___ Sleeve Gastrectomy (DS Staged) ___ Lap Band ___ Unsure at this time *please note: some insurance companies do not cover all procedures _______________________________________________________________________________________

Physician Care Information: (if you do not see this type of physician, please check “n/a”) Primary Care Physician:___________________________________ Internist: _______________________________________________ Cardiologist: ___________________________________________ Pulmonologist: __________________________________________ Psychiatrist/Psychologist: _________________________________ Gynecologist/Urologist: ___________________________________ Neurologist: ____________________________________________ Other: _________________________________________________

____ n/a ____ n/a ____ n/a ____ n/a ____ n/a ____ n/a ____ n/a ____ n/a

Phone #: _______________ Phone #: _______________ Phone #: _______________ Phone #: _______________ Phone #: _______________ Phone #: _______________ Phone #: _______________ Phone #: _______________

Diet History Information: (this information will be shared with the insurance company) Please check if you have tried any of the following diet plans/programs/pills: Atkins Hypnotism Calorie Counting Jenny Craig Health Spa Opti-Fast/Medi-Fast Herbal Life LA Weight Loss High Protein Nutri System Low Carb Weight Watchers Low Fat Over Eaters Anonymous Mayo Clinic TOPS Richard Simmons Exercise/Gym Program ____________ Slim Fast Dexatrim Acutrim South Beach Sugar Busters Fen-Phen Cabbage Soup Meridia Zone Prozac Binging/Purging Redux Fasting Xenical Wellbutrin Physician Supervised Diets

Premier Metabolic and Bariatric Associates Registration-2Name: ____________________________ _______________________ Date of Birth: _____________ Last (please print)

First

_____________________________________________________________________________________ Medication Information: Medication Name

Dosage/Units

Frequency

If you have attached a medication list, please check here Are you taking any Vitamins? Yes No If yes, list them: _______________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________________

Allergies: Check here if you have no known allergies Please check below if you are allergic to any of the following: Latex Allergy Iodine Allergy IV Contrast Allergy Adhesive Allergy Drug Allergy : name: ______________________________________________________________ Other Allergies: ___________________________________________________________________ _____________________________________________________________________________________________

Previous Surgery History: Name of surgery

Year

Hospital

Doctor

_____________________________________________________________________________________________

Disability Information: Year of disability ________ Check here if you are disabled Type of disability : _________________________________ (accident, illness, work injury etc.) Do you require assisted devices? __ cane __ walker ___crutches Do you require a wheelchair or motorized scooter? Yes No

Premier Metabolic and Bariatric Associates Registration-3Name: ____________________________ _______________________ Date of Birth: _____________ Last (please print)

First

___________________________________________________________________________________ Family History:

Does anyone in your family have any of the conditions listed below?: Diabetes: Hypertension: Cardiovascular: Stroke: Cancer: Obesity: Renal Failure: Arthritis Other :___________

(circle one) Mother Mother (circle one) Mother (circle one) Mother (circle one) Mother (circle one) Mother (circle one) Mother (circle one) Mother (circle one) Mother (circle one)

Father Father Father Father Father Father Father Father Father

Sister Sister Sister Sister Sister Sister Sister Sister Sister

Brother Brother Brother Brother Brother Brother Brother Brother Brother

Grandmother Grandmother Grandmother Grandmother Grandmother Grandmother Grandmother Grandmother Grandmother

Grandfather Grandfather Grandfather Grandfather Grandfather Grandfather Grandfather Grandfather Grandfather

Social History: Do you currently smoke? Yes No (circle one) How many packs per day? ________ I was a smoker but I have quit. Quit date: ____________ How long smoke free? ________ Do you drink Alcohol? How many times?

Yes No ___ Daily

(circle one) ___ Monthly

___special occasions only

Do you use Illicit drugs? Yes No (circle one) How often? ___ Daily ____ Weekly ___ Monthly Type: ___Marijuana ___Cocaine ____Ecstacy ___ Heroin ___ prescription drugs ___ Other: _________________________________________________________________ I was a drug abuser, but I have quit. Quit date: ___________ How long drug free?_______ _____________________________________________________________________________________________

Other Hospitalizations: (non surgical ex: psychological, injury, disease) Illness Year Hospital

Doctor

Premier Metabolic and Bariatric Associates Registration-4Name: ____________________________ _______________________ Date of Birth: _____________ Last (please print)

First

Please check (√) any of the following diagnosis that you have had (diagnosed by a physician)

√

Condition Name Angina/Chest Pain Allergic Rhinitis Anxiety Asthma

√

Condition Name DVT (Deep Vein Thrombosis) DDD (Degenerative Disc Disease) Depression

Arthritis Type: _________ Anemia Breast Cancer

Diabetes Type I Controlled Uncontrolled Diabetes Type II Controlled Uncontrolled Dysfunctional Uterine Bleeding Dysmenorrhea Shortness of Breath

Bleeding Disorder

Dentures

Bipolar Disorder CAD (Coronary Artery Disease) Cardiomyopathy/heart muscle disease

Elevated Liver Enzymes Fatigue

Atrial Fib/Irregular Heartbeat

Carpal Tunnel Syndrome Chest pain with exertion Cancer Type:__________ Congestive Heart failure

√

Condition Name

Sleep Apnea

H-Pylori

Urinary Stress Incontinence Thrombophlebitis

Hiatal (esophageal) Hernia High Blood Pressure

Venous Insufficiency

Insomnia/trouble sleeping Muscle pain in legs Intertriginous Dermatitis Irritable Bowel syndrome Joint Pain Menstrual Irregularity

Pain In: Ankles feet Elbows Hands Hips Knees Neck back Shoulder Wrist

GERD/heartburn Glucose intolerance

Myocardial Infarction Peripheral Edema (swelling legs/ankle) Peripheral Vascular Disease (blockage of arteries) Peptic Ulcer

Gastroparesis (slow digestion problems)

Colitis

High Cholesterol

Cholelithiasis/gallstones

Hepatitis

Chronic Back Pain CVA/stroke

Hypertriglyceridemia Low thyroid

Hemorrhoids

Varicose veins

Infertility

Metabolic Syndrome

COPD (Chronic Obstructive Pulmonary Disease) Colon Cancer

Condition Name

High Thyroid

Fatty Liver Alcoholic Non-alcoholic Fibrocystic disease

Gout

√

Migraine Headaches

Polycystic ovarian syndrome Pseudotumor Cerebri Pulmonary Embolism (blood clot to lungs) Seasonal Allergies Sleeping Disorder

Osteoarthritis In: Ankles feet Elbows Hands Hips Knees Neck back Shoulder Wrist Kidney Disease Seizures

Premier Metabolic and Bariatric Associates Registration-5Name: ____________________________ _______________________ Date of Birth: _____________ Last

(please print)

First

Premier Metabolic and Bariatric Associates Information Session for Surgical Weight Loss I ______________________________________________ have attended the (Print your full name)

Educational/Informational session about Surgical Weight Loss, done by Premier Metabolic and Bariatric Associates. Potential patients with their support person came to a scheduled information session. Advantages, disadvantages, risk, benefits and complications of the surgeries done Open or Laparoscopic (Roux en Y Gastric Bypass, Duodenal Switch/BPD, Sleeve Gastrectomy, and Lap Band) were discussed. The effectiveness of obesity surgery was discussed in great detail. Questions were answered at a level that could be understood. The patient was informed of the length of his/her hospital stay and what to expect while in the hospital. The patient was also informed of what to expect after he/she goes home, including his/her new eating habits. Persons having gastric surgery must be committed to life long follow up care. Diagrams were shown of all the surgeries that Premier Bariatric Associates perform. Letter will be written to potential patient’s insurance companies for authorization, after they have turned in all necessary paperwork required by Premier Metabolic and Bariatric Associates and/or the insurance companies. Signed: _________________________________________________ Date: ___________________________________________________