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Ucla bariatric surgery patient history questionnaire
UCLA BARIATRIC SURGERY PATIENT HISTORY QUESTIONNAIRE
Your appointment will be delayed if this form is incomplete
PLEASE PRINT LEGIBLY
PERSONAL INFORMATION: Name:
_______________ SSN# (for insurance purposes
)_______-______-________ Date of Birth
: _________________ Age
: __________ Mailing Address:
______________________ Daytime Phone:
_________________________________ Home Phone:
_________________________________ Cell phone:
__________________________________________ Martial Status:
Single Married Divorced Widowed Gender:
Male Female Occupation
:____________________________________________ How may hours a week do you work
Number of Children
_______ Ages of Children
__________________ Do you care for elder relatives
________ What is your involvement in the care
_________________________________________________ With whom do you reside?
________________________________________________________ How long have you been contemplating bariatric surgery?
___________________________________________ Have you done any research regarding bariatric surgery?
________ If YES, what type
______________________________________________________________________________ How did you hear about this program?
____________________________________________________________ Do you have a friend or family member who has had bariatric surgery?
______ Who?____________________ Primary Language Spoken_____________________ Primary Language Reading ________________________
(DO NOT FILL IN: THESE NUMBERS WILL BE OBTAINED AT THE TIME OF YOUR APPOINTMENT) HEIGHT
Ideal Body Weight
Excess Body Weight
PERSONAL MEDICAL HISTORY: (Do you have or have you ever had. Check all that apply)
swollen easily? Do you take medication for the
getting short of breath? Is it getting worse?
Allergic to any medications
? Yes No Surgical tape:
Yes No Latex:
Yes No Iodine:
Yes No If yes, please list medication and reaction:
Age you first started dieting
:_______ Approx. weight at age 18
___________ Current Weight
: ___________Weight range last 5 years
What was the most successful weight loss you have achieved and how did you do it? _________________________
What behaviors did you learn from dieting that you still use today?_______________________________________ FOOD PREFERENCE:
Are you a sweet eater?
Yes No If so, what
?___________________________________________________ How often
Are You a pasta/bread eater?
Yes No If so, what?
______________________________________________ How often?
______________________________________________________________________________ Are you a fast food eater?
Yes No If so, what
?_________________________________________________ How often?
______________________________________________________________________________ Do you snack between meals?
Yes No If so, what do you snack on?
______________________________ How often
Is snacking from habit?
Yes No Boredom?
Yes No Do you binge eat?
Yes No How often
?___________________________________________ What Beverages do you consume throughout the day
? _______________________________________________ Quantity?
SOCIAL / FAMILY HISTORY: Is there Obesity in the family?
Yes No Who
:_______________________________________________ Other medical illness within the family:
Yes No If so, what
: Diabetes Hypertension
Coronary Artery Disease Other____________________________________________________ Do you exercise regularly?
Yes No If so, what do you
do:_________________________________________ Do you have any physical restrictions that keep you from exercising?
Yes No Explain
_____________________________________________________________________________________________ Have you ever smoked cigarettes / cigars?
Yes No Do you smoke now?
Yes No When did you quit?
_______________ How much did you smoke per day?
_____________________________ Do you drink alcohol?
Yes No What type of alcohol do you consume?
___________________________ More than 5 drinks per week?
Yes No Less than 5 drinks per week?
Yes No Have you or are you currently using any recreational/ illegal drugs
? Yes No Explain
:______________________________________________________________________________________ Do you have a history of abuse? (Please include emotional, physical, mental, substance or other types of abuse
issues you’ve dealt with. This information is extremely important and very confidential. Honesty is needed
in order to provide you with the best possible treatment plan) Describe your present life stressors: Describe the present support system you rely upon. (Church, spouse, family, friends, co-workers, etc):
What is your greatest fear regarding the surgery? What is your greatest hope regarding the surgery
? Why do you (What is motivating) to seek this type of interventions for weight control
(COMPLETE INFORMATION IS MANDATORY INCLUDING ADDRESS/FAX/TEL)
Phone & Fax Numbers
Please return completed form along with a copy of your insurance card and current
authorization (if applicable) to:
UCLA Medical Center
Minimally Invasive Bariatric Surgery Program
Attn: Program Coordinator
Los Angeles, CA. 90095-6904
Fax: (310) 267-4632
2010 Health Form Page 1 of 4 Camper Name Please complete and RETURN TO CAMP BY MAY 1st for all sessions. PLEASE PRINT. If enrolling after May 1st, please return ASAP. Camper Name : ___________________________________________ Session: ________________ :_____________________________ (For Camp Use) Age : _____________________ Birthday : __________________________ Gender
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