Bariatrics Intake Form

Patient Information

Name *

Date of Birth *

Month

Day

Year

Gender *

Phone *

Email *

Medical History

Conditions

Select all that apply to you

Other Condition

Surgical History

Select all that apply to you

Other Surgery

Mobility Status *

Are you disabled? *

Reason Disabled

Assistive Device(s)

Years in assistive device(s)

Have you had a Colon Cancer Screening? *

Date of last screening:

Month

Day

Year

Have you had a Mammogram? *

Date of last mammogram:

Month

Day

Year

Social History

Do you use alcohol? *

How many drinks per week?

Glasses of wine

Cans of Beer

Shots of liqour

Comments on alcohol use

Have you used drugs for non-medicinal purposes? *

How many times per week?

Marijuana

Cocaine

Inhalants

Methamphetamine

IV

Other

Date last used

Month

Day

Year

Comments on drug use

Bariatric Sleep Assessment

Please estimate your risk of falling asleep in the following situations, using this scale:

0 = No chance, 1 = Slight chance, 2 = Moderate chance, 3 = High chance

Sitting and Reading *

Watching TV *

Sitting or inactive in a public place (theater or meeting) *

Lying down to rest in the afternoon *

Sitting and talking to someone *

Sitting quietly after lunch without alcohol *

Sitting in a car while stopped in traffic *

Sitting in a car for an hour without a break *

Sleep Assessment Total:

Have you made previous weight loss attempts, including prescribed medication? *

What medicines have you tried?

What type of weight loss surgery are you interested in? *

Revision Information

What type of Bariatric surgery did you have previously?

When was your previous surgery?

Where was your previous surgery performed?

Reason for seeking a revision:

Risk Assessment for Bariatric Surgery

Score of 3 – 4: 2-week course of Lovenox 40mg BID

Score of 5 or higher: 4-week course of Lovenox 40mg BID

Gender *

Are you 60 years or older? *

Is your BMI at least 50? *

Have you ever had DVT or Pulmonary Embolism *

Do you have a diagnosed clotting disorder? (Factor V Leiden, Factor II Mutation, etc) *

Do you have severe venous insufficiency? (Blood flow problems in your legs, where skin is purple-brown or has ulcers?) *

Have you been diagnosed with Congestive Heart Failure? *

Do you have difficulty breathing, even while resting? *

Are you paralyzed? *

Risk Assessment Total:

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Patient Information

Medical History

Social History

How many drinks per week?

How many times per week?

Bariatric Sleep Assessment

Revision Information

Risk Assessment for Bariatric Surgery