comprehensive weight loss management intake form - Kaleida Health

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BARIATRIC APPLICATION PACKET 1 OF 10
Patient Name:
Date of Birth:
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
Financial Number
COMPREHENSIVE WEIGHT LOSS MANAGEMENT INTAKE FORM
This page to be filled out by patient.
Telephone Number: (Home) (Cell) (Work)
Height: Weight: BMI:
Address:
Requesting Doctor:
Primary Medical Doctor:
Insurance Information:
Patient Email:
Please mail entire 10 page packet to the address below. The entire packet must be received
before you can be scheduled for your initial visit.
The Center for Minimally Invasive Surgery
Buffalo General Hospital
100 High Street
Buffalo NY, 14203
Attn: D3 CWL Clinic Application Office
Application Information Phone: 859-2067
Application Fax: 859-3352
www.KaleidaHealth.org
Click on the Bariatrics tab
KH01038 Rev. 02/21/13
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BARIATRIC APPLICATION PACKET 2 OF 10
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
BARIATRIC SURGERY QUESTIONNAIRE
This page to be filled out by patient.
Financial Number
Please complete ALL questions. Each question of the application is REQUIRED for insurance authorization.
First Name: __________________ Last Name:___________________ Age:______ Date of Birth:
What age did you first consider yourself overweight? ________ What was your weight at that time?
What was your weight in high school? ________ What was your heaviest weight? ________
Please list other ages and weights you remember. Why do you remember your weight at that age? If you have had
children, list your weight at the time of birth, and your weight once the pregnancy weight was gone.
Age Weight Event which you are recalling
Please list your current weight: ______________________ Please list your height:
Which diet plans have you tried to lose weight in your lifetime (this MUST reflect at least five years of unsuccessful
weight loss attempts.) Please list the approximate month and year you started and stopped each plan, how much
you lost, and how much weight you regained once you stopped the plan.
Check all
that apply
Diet Plan
Approx.
Start Date
Approx.
End Date
Approx.
Weight Loss
Approx.
Weight Regain
Jenny Craig
Weight Watchers
Atkin’s Diet
Cabbage Soup Diet
Grapefruit Diet
South Beach Diet
Slim Fast
Dietician Directed Plan
Physician Directed Plan
Other Plans
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BARIATRIC APPLICATION PACKET 3 OF 10
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
BARIATRIC SURGERY QUESTIONNAIRE
This page to be filled out by patient.
Financial Number
Which exercise plans did you try? Please list the approximate month and year you started and stopped each plan,
how much you lost, and how much weight you regained once you stopped the plan.
Check all
that apply
Exercise Plan
Approx.
Start Date
Approx.
End Date
Approx.
Weight Loss
Approx.
Weight Regain
Curves for Women
Gold’s Gym
Buffalo Athletic Club
Richard Simmon’s Tape
Personal Trainer
Other
What do you typically eat for each meal? List your snack and “comfort” foods.
Breakfast
Morning Snack
Lunch
Mid-Day Snack
Dinner
Late Night Snack
Comfort Foods
What medications did you use to lose weight? Please list the approximate month and year you started and stopped
each medication, how much you lost, and how much weight you regained once you stopped the medication.
Check all
that apply
Medication
Approx.
Start Date
Approx.
End Date
Approx.
Weight Loss
Approx.
Weight Regain
Phen-Fen
Meridia
Xenical
Ephedra
Amphetamine
Metabolife
Others
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BARIATRIC APPLICATION PACKET 4 OF 10
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
BARIATRIC SURGERY QUESTIONNAIRE
This page to be filled out by patient.
Financial Number
Several medical problems can be related to weight. Do you have any of the conditions listed below? If so, please
list the date they occurred, your treatment (if any), whether or not you are still undergoing treatment, and what
symptoms (if any) you currently have.
Condition Onset Date Treatment
Still
Treated?
Current Symptoms
High blood pressure
High cholesterol
Shortness of breath with
exercise
Sleep apnea
Asthma
Diabetes
Acid reflux (GERD)
Bladder problems
Back pain
Hip pain
Knee pain
Ankle pain
Foot pain
Leg swelling
Depression
Do you have problems in? Or problems with? (please explain)
Check all
that apply
Problems
Explain
Eyes
Ears
Nose
Mouth
Neck
Back
Chest or Lungs
Heart
Blood Vessels
Abdomen (Belly)
Intestines
Liver
Kidneys, Urine or Bladder
Genitals
Legs
Endocrine/glandular abnormalities
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BARIATRIC APPLICATION PACKET 5 OF 10
What other medical conditions do you have?
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
BARIATRIC SURGERY QUESTIONNAIRE
This page to be filled out by patient.
Financial Number
Have you ever had surgery? Please list all surgical procedures and dates you had them:
Have you ever had bariatric surgery in the past? (circle one) Yes No
If so, when: _______________ Where: _____________________
With Whom:
How many times were you pregnant? What was the result of each pregnancy?
Have you had a colonoscopy or stomach scope? If so, when?
Have you had an abnormal CAT scan or X-ray test for which you had to drink a contrast substance? If so, when?
What medications do you take? (Please list prescription, over the counter, vitamins, protein shakes, mineral pills
etc. Please include the one(s) you only occasionally take).
Medication Dose Number of Times Per Day
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BARIATRIC APPLICATION PACKET 6 OF 10
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
BARIATRIC SURGERY QUESTIONNAIRE
This page to be filled out by patient.
Do you have allergies to medications? List the medication, and what happens if you take it.
Financial Number
Do you have any environmental allergies?
Do you smoke?________ How much per day?_______________ For how many years?
Do you drink alcoholic beverages?______________ How much, and how often?
Do you use any illicit/recreational drugs?
Have you ever had a drug or alcohol problem? (explain details)
Are you married? _________________________
Who do you live with?
What do you do for work?
What medical conditions are present in your family?
Mother:
Father:
Siblings:
Person completing questionnaire:
Relationship to patient:__________________________ Date the questionnaire was completed:
Physician Reviewer: _________________________________________ Date: _________________________
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BARIATRIC APPLICATION PACKET 7 OF 10
RE:
DOB:
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
Financial Number
PRIMARY CARE PHYSICIAN REFERRAL
This page to be completed by Referring Primary Care Physician.
Dear Dr’s Posner, Hoffman and Butsch,
The Center for Minimally Invasive Surgery
Kaleida Health-Buffalo General Hospital
100 High Street, Buffalo, NY 14203
716-859-1168 (Office)
716-859-2067 (Application office)
716-859-3352 (Fax)
I am referring
to be considered for weight loss surgery for obesity.
This patient has been under my care for the past ___________ years. Despite numerous attempts,
remains obese. The patient currently weighs _______ pounds and is
_______ feet and _______ inches, which calculates to a Body Mass Index (BMI) of _______. During the past five
years the patient’s weight has been documented as follows:
Year
Weight
The patient’s co-morbidities include:
.
has tried many diets and exercise programs including:
.
These diets and exercise programs were medically approved and supervised.
The patient’s most recent TSH level is ____________ and was last tested .
She/He is currently taking the following medications:
.
In the past, I have treated her/him for the following medical conditions, with the following results:
.
I am currently treating this patient for:
.
I have confidently ruled out other causes of obesity and can be contacted at
if you have any questions.
Physicians Signature Required Date Time
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BARIATRIC APPLICATION PACKET 8 OF 10
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
Financial Number
MEDICAL CLEARANCE FORM/PT ASSESSMENT
This page to be completed by Referring Primary Care Physician.
(Patient) _______________________________, DOB: ______________ wishes to take
part in an exercise program and/or fitness assessment. The exercise program may include
progressive resistance training, flexibility exercises, and a cardiovascular program;
increasing in duration and intensity over time. The fitness assessment may include a submaximal
cardiovascular fitness test and measurements of body composition, flexibility,
muscular strength and endurance. Please identify any recommendations or restrictions for
your patient’s fitness program below (Physicians Recommendations).
Physician’s Recommendations/ Physical Therapy Referral
I am not aware of any restrictions toward participation in a fitness program.
I believe the applicant can participate, but urge caution because:
The applicant should not engage in the following activities:
I recommend the applicant not participate in the above fitness program.
Physician’s Signature
Date/Time
Physician’s Name (Print) Phone: Fax:
Address: City: State & Zip:
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BARIATRIC APPLICATION PACKET 9 OF 10
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
PERSONAL LETTER
This page to be filled out by patient.
Financial Number
Dear Center for Minimally Invasive Surgery Staff:
My name is _________________________________ and my date of birth is .
I have been struggling with obesity for ___________ years. I have tried many avenues to lose
weight over the years such as,
.
I feel I would be an ideal candidate for bariatric surgery because,
.
I believe bariatric surgery will positively impact my life by
.
Please consider me for the program because
.
Thank you for your time and consideration!
Signature
Date
* You may use this template as your personal letter or you may write your own if you prefer. *
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BARIATRIC APPLICATION PACKET 10 OF 10
Patient Name
Date of Birth Admission/Visit Date Site
Medical Record Number
Patient ID Area
PHYSICAL THERAPY QUESTIONNAIRE
This page to be filled out by patient.
Financial Number
Patient Name:
DOB:
When you come for your initial visit you will also see the physical therapist for a fitness
assessment and to discuss an exercise program for you. Please wear comfortable clothes and
shoes for your visit.
The doctors want to see each patient performing at least 30 minutes of aerobic/strength
exercises each day. This is to assist you with your pre-surgery weight loss and improve your
cardiac fitness for surgery. You will continue to exercise after surgery to continue helping you
with your weight loss and physical fitness goals. Hopefully one year after surgery you will be
more physically fit then you are today!
Are your presently doing any walking or exercise?
If yes, what are you doing?
How many minutes each day?
Do you have a gym membership?
If not, do you plan on joining a gym?
Do you have any home exercise equipment? (check all that apply):
___ Ab-Lounge
___ Exercise Ball
___ Bicycle
___ Elliptical
___ Exercise Bicycle
___ Free Weights
___ Gazelle
___ Total Gym
___ Treadmill
___ Videos
___ Weight Machine
___ Wii
___ Wii Fit
___ Xbox Kinect
Other equipment:
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