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: __________________________________________________________________
Date: _______________
SSN# (for insurance purposes)_______-______-________
Date of Birth: _________________
Age: __________
Mailing Address: ______________________________________________________________________________
City:__________________________________________
State: ______________
Zip: ______________________
Daytime Phone: _________________________________
Home Phone: _________________________________
Cell phone: __________________________
E-Mail Address: __________________________________________
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________
Who________
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)
Cardiovascular
Gastrointestinal
swollen easily? Do you take medication for the
Gynecological
Endocrine
Respiratory
Hematological
getting short of breath? Is it getting worse?
Psychological
Surgeries:
Hospitalizations:
TREATMENT
Prescription Medications:
MEDICATION
FREQUENCY
Non-Prescription Medications:
MEDICATION
FREQUENCY
ALLERGIES:
Allergic to any medications? Yes No
Surgical tape: Yes No
Latex: Yes No
Iodine: Yes No If yes, please list medication and reaction:
_____________________________________________________________________________________________
DIETING HISTORY:
Age you first started dieting:_______
Approx. weight at age 18______
Height: ___________
Current Weight: ___________
Weight range last 5 years _______
to ________
Duration
MD
supervised?
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?
Physicians:
(COMPLETE INFORMATION IS MANDATORY INCLUDING ADDRESS/FAX/TEL)
Specialty
Phone & Fax Numbers
Signature:_____________________________________________________ DATE:_____________
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
Box 956904
Los Angeles, CA. 90095-6904
Fax: (310) 267-4632
Source: http://bariatrics.ucla.edu/workfiles/SurgeryQuestionnaire.pdf
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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