Patient Information

Fields marked with an * are required.
First Name:
Last Name:		 *
* 		 
Address 1: * City: *
Address 2: Apt.# State: *   Zip: *
Home Phone: (###)###-#### * Work Phone:(###)###-####
Mobile Phone:(###)###-#### Email Address: *
Your Occupation: *
Employer: *
Employer Address 1: City:
Employer Address 2: (e.g. Suite #) State:   Zip:
Date of Birth (MM/DD/YYYY): * Age: *
Social Security: (123456789)
Driver's License #:
Marital Status: Married:   Single:   Divorced:   Widowed:
Primary Health Insurance: PPO:   HMO:   POS:
ID #: Policy #:
Group #: Insurance Customer Service Phone #:
Principle Insurance Holder: Self:   Spouse:   Other:
Secondary Health Insurance: PPO:   HMO:   POS:
ID #: Policy #:
Group #: Insurance Customer Service Phone #:
Principle Insurance Holder: Self:   Spouse:   Other:
 

Which procedure are you considering?

Roux-en-y, Gastric By-pass   Lap-Band, Adjustable Gastric Banding   Haven't Decided

 
Have you contacted your insurance company regarding your benefits with regards to either procedure? Yes:   No:
Does your insurance policy cover weight loss surgery? Yes:   No:
 
If your insurance company does not cover the surgery, would you be interested in financing or paying cash for the surgery if your insurance does not cover it? Yes:   No:

Emergency Contact or Next of Kin

Name:
Address 1: City:
Address 2: (e.g. Apt#) State: Zip:
Phone:
Relationship: Spouse:   Partner:   Parent:   Friend:   Other:
Referring Physician:
 

Primary Care Physician

Name:
Address 1: City:
Address 2: (e.g. Suite #) State:   Zip:
Phone:
Fax:
How long have you been thinking about this surgery?:
Which best describes your situation?: (Select one.)
 

Where did you hear about our Program? (Please check all that apply)

Seguin Daily News KWED - AM - Seguin Friend
Seguin Gazette-Enterprise WOAI - San Antonio Physician
Senior News Luling Newsboy Other
Wilson County News Billboard  
La Vernia News Internet  
 

Weight Loss History:
At what age did you begin dieting?:
What is your current: Height: * ft., * inches, Weight: * lbs.
Weight Loss Programs/Diets/Medications:
Please list your weight loss attempts in the past 10 years. Be as specific as possible. Most insurance companies will not approve this surgery unless we can identify sufficient attempts at weight loss. Diets/medications may include but are not limited to the following: Jenny Craig, Weight Watchers, Nutri-System, Low-Cal, Low-Fat, Low-Carb, Atkins, Phen-fen, Meridia, Xenical, Phentermine, Exercise Program, Medi-fast, Opti-fast and etc...
Program/Diet/Medication Name Physician Monitored Y/N How long did you participate? Did you exercise? What were your results?
Example: Weight Wathcers Yes, by Dr. Someone 8 months Yes Lost 50 lbs. and regained 75 lbs.
 

Health Questionnaire

Please list any medications to which you are ALLERGIC:
Medication Reaction:
 
Please list any prescription medications, vitamins and/or/ herbal supplements you are presently taking:
Medication: Dosage: Frequency:
 
Please list all surgeries and hospitalizations:
Date: Procedure/Diagnosis: Hospital Name/Location:
 

Do you have a mental health condition?   Yes   No *

* If yes, please describe: (example, bi-polar disorder, schizophrenia, major depression)

Family History:

Please check which, if any, of your family members had any of the following conditions:
Condition: Mother Father Siblings Grandparent Aunt/Uncle
Anemia
Bleeding Problems
Blood Clots
Cancer
Diabetes
Gallstones
Gout
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Kidney Stones
Obesity
Sleep Apnea
Stroke
Comments:
 
Obesity Related Symptoms: (please check all that apply:)
Leg-cramping
Rash/Dermatitis
Coughing or choking at night
Shortness of breath
Swollen Ankles/Feet
Heartburn/esophagitis
Leakage of Urine
 

Medical Conditions:

Condition: No Yes
Alcoholism
Anemia
Anorexia
Asthma
Arthritis
Bladder/Kidney infections
Blood Clots in your legs
Bulimia
Cancer
Colitis or Irritable Bowel Syndrome
Diabetes Mellitus
Depression
Epilepsy/Siezures
Gastric Reflux
Gout
Heart Attack
Heart Failure
Heart Murmur
Hemorroids
Hepatitis
High Cholesterol
High Blood Pressure
Joint Pain
List joints affected if any:
Kidney Stones or Disease
Liver Disease
Lung Disease/Pneumonia
Migraine/Severe Headaches
Rheumatic Fever
Sleep Apnea
Stroke
Stomach Ulcers
Thyroid Trouble Hypo/Hyper
Tuberculosis
Tumors
Varicose Veins
 
Are you a smoker? No   Yes  Packs/day:
Have you ever been a smoker? No   Yes  Age Started:   Age Quit:
Do you consume alcohol? No   Yes  Drinks/day:
Do you use recreational drugs? No   Yes  Type/frequency:
 
Women Only:
Date of last menstrual period:
Are your menstrual periods regular?:
Are you using birth control? Yes   No  If yes, what type?
Number of pregnancies:   Number of live births
Have you had trouble becoming pregnant? No   Yes
Other Comments:
 
Exercise:
Please describe your exercise routine. Include type of exercise, frequency and physical limitations.
 
Other Concerns:
Please write any other concerns that you may have regarding your health or weight loss surgery.
 
Goals:
Please list in order of importance what you want to accomplish by having weight loss surgery.