Mercy Metabolic and Bariatric Surgery Program Questionnaire

Interested in bariatric surgery? Complete this form and return to us to be considered for evaluation:

Sara Maduka, Mercy Metabolic and Bariatric Surgery Program Director

Office: 319.688.7693 | Cell: 319.325.8739 | Fax: 319.688.7881
540 East Jefferson Street Suite 205
Iowa City, IA 52245

**Note: complete the entire form or it will be returned to you**

Name: / Date:
Age: / Date of Birth: / Sex:
Address: City:
State: / Zip:
Phone:
Home: ( ) - / Work: ( ) -
Cell:
Email:
Race/Ethnicity:
□ African American □Caucasian □Hispanic □Native American □Asian □Other
What procedure are you interested in:
□ Laparoscopic adjustable gastric band □Laparoscopic Roux-en-Y gastric bypass
□Laparoscopic sleeve gastrectomy
Insurance:
Insurance #1:
ID #: / Group #:
Policy Holder: / Relationship:
Customer Service Phone #:
Insurance #2:
ID #: / Group #:
Policy Holder: / Relationship:
Customer Service Phone #:
How did you hear about our program?
□ Web □ TV □ Radio □ Newspaper □ Seminar □ Mercy Employee □ Family/Friend
□ Mercy Patient □ Insurance Company
□ My Physician: Name: Phone #: ( ) - )
Do you currently smoke? □Yes □No
Current Height: feet inches / Current Weight:
Highest weight since age 18: / Lowest weight since age 18:
Age when obesity began:

Current Medications: Include prescription and over the counter:

□ None
Medication: / Dosage: / How often:
Medication: / Dosage: / How often:
Medication: / Dosage: / How often:
Medication: / Dosage: / How often:
Medication: / Dosage: / How often:
Pharmacy:
Primary Care Provider:

Surgical History (ALL surgeries and procedures, including those that are bariatric/for weight loss):

□ None
Type: / Reason: / Date:
Type: / Reason: / Date:
Type: / Reason: / Date:
Type: / Reason: / Date:

Drug Allergies:

□ None
Drug: / Reaction:
Drug: / Reaction:

Currently or in the past six months, have you experienced any of the following:

Yes/No / Condition / Yes/No / Condition / Yes/No / Condition
□ □ / Abnormal belly pain / □ □ / Headache / □ □ / Rectal bleeding/pain
□ □ / Blood in stools / □ □ / Hearing loss/ear pain / □ □ / Shortness of breath
□ □ / Bowel habit changes / □ □ / Indigestion / □ □ / Sore throat/cough
□ □ / Chest pain / □ □ / Itching/rash / □ □ / Sweats
□ □ / Depression/anxiety / □ □ / Loss of sleep / □ □ / Unexplained weight loss
□ □ / Dizziness/fainting / □ □ / Nausea / □ □ / Vision changes/eye pain
□ □ / Excessive thirst / □ □ / Numbness / □ □ / Vomiting
□ □ / Excessive bleeding / □ □ / Pain/problems urinating
□ □ / Fever / □ □ / Poor appetite / □ □ / Other

Health issues, past and present (please mark all that apply):

Past/Present / Condition / Medication/Treatment
(name, dose) / Notes
(Office use)
□ □ / High Blood Pressure
□ □ / Diabetes
□ □ / Sleep Apnea
□ □ / Daytime Sleepiness
□ □ / Snoring
□ □ / Reflux/Heartburn
□ □ / Heart Disease
□ □ / High Cholesterol
□ □ / High Triglycerides
□ □ / Joint Pain
□ □ / Back Pain
□ □ / Hip Pain
□ □ / Knee Pain
□ □ / Ankle and Foot Pain
□ □ / Foot Swelling
□ □ / Urinary stress/Incontinence
□ □ / Blood Clots
□ □ / Stroke
□ □ / Shortness of breath
□ □ / Asthma
□ □ / Emphysema
□ □ / Headaches
□ □ / Migraines
□ □ / Kidney Disease
□ □ / Seizures
□ □ / Rashes
□ □ / Arthritis
□ □ / Cancer
□ □ / Irregular Periods
□ □ / Eating disorder
□ □ / Other (please explain)
Past/Present / Psychiatric History / Medication / Hospitalized* Dates / Explain (next pg.)
□ □ / Depression / □ No □Yes
□ □ / Severe depression / □ No □Yes
□ □ / □ Schizophrenia/ □Bipolar / □ No □Yes
□ □ / □Anorexia/ □Bulimia / □ No □Yes
□ □ Do you see a psychologist, psychiatrist, or counselor for mental health issues?
□ Yes* □ No (If so, please include a recent psychiatric evaluation including history, diagnosis, and treatment.)

Continued Psychiatric History – Explanations*:

______

Medical History: (list any other conditions not already listed):

Condition: / Medication: / Dosage:
Condition: / Medication: / Dosage:
Condition: / Medication: / Dosage:

Family History: (Please mark all that apply)

Severe Obesity / Heavy / Normal Weight / Bariatric Surgery / Diabetes / Heart Disease / Cancer / Hyper-tension / Blood Disease
Father
Paternal Grandfather
Paternal Grandmother
Father’s Brothers
Father’s Sisters
Mother
Maternal Grandfather
Maternal Grandmother
Mother’s brothers
Mother’s sisters
Sisters
Brothers
Sons
Daughters

Personal History of Weight Gains and Losses (since age 18):

□ No pattern

□ Steady, gradual increase of weight

□ Sudden increases of weight with pregnancies

□ Variable weight gains and losses due to diet and exercise fluctuations

Exercise History:

□ I am unable to exercise due to:

□ severe joint pain □ shortness of breath □ wheelchair/bedridden

□ I am able to exercise but I do not have a regular routine

□ I walk/run _____ times per week for _____ minutes

□ I swim _____ times per week for ______minutes

□ I lift weights _____ times per week for ______minutes

□ Other (please describe): ______

Dietary History: Please check all that describe your daily eating pattern

□ Less than normal □ Normal □ Overeat □ Binge □ Serious eating disorder □ Excessive snacking

Do you eat/snack just before bed? □ Yes□ No

Which meals do you regularly eat? □ Breakfast □ Lunch □ Supper □ Snacks

What do you eat for breakfast, and how much? ______

What do you eat for lunch, and how much? ______

What do you eat for supper, and how much? ______

What do you eat for snacks, and how much? ______

Do you drink soda? □ No □ Yes: How many 12 ounce servings each day? Diet: _____ Regular: ______

Do you drink juice? □ No □ Yes: What kind? ______How many 12 ounce servings each day? _____

Social and Personal History:

Highest level of education: ______

Occupation: ______□ Part-time □ Full-time

Employer name: ______

Do you have children? □ No□ Yes: how many? ______

Marital Status: □ Single□ Married□ Separated□ Divorced

Have you ever smoked tobacco? □ No □ Yes

If yes, do you currently smoke?

□ No: when did you quit? ______How many packs per day? ______

□ Yes: year you started? ______How many packs per day? ______

Have you ever used chewing tobacco: □ No □ Yes

If yes, do you currently chew?

□ No: when did you quit? ______How many cans per day? ______

□ Yes: year you started? ______How many cans per day? ______

Do you have a history of alcohol abuse?□ No □ Yes: when was your last drink? ______

Do you consume alcoholic beverages? □ No □ Yes: how many drinks per week? ______

Do you have a history of drug/substance abuse? □ No □ Yes

Do you currently use drugs?

□ No: What drugs have you used?______When did you quit?______

□ Yes: What drugs are you using? ______

Female Reproductive History:

Current method of birth control: ______

Number of: Pregnancies: ______Vaginal deliveries: ______C-Sections: ______

1st Pregnancy: ______(year) ______(age)______pounds gained

2nd Pregnancy: ______(year) ______(age)______pounds gained

3rd Pregnancy: ______(year) ______(age)______pounds gained

Age at first period: _____Did you breastfeed your babies? Yes/NoHow long? _____

Have you ever taken birth control pills? Yes/NoHow long? ______

Date of last menstrual period? ______Date of last PAP? ______

Date and location of last mammogram?______Family history of breast cancer? Yes/NoWho? ______

Summary of Weight Loss Attempts: Provide a list of supervised diet attempts over the past five years (start with most recent). Most insurers require monthly documentation for at least three to six months.

Medically Supervised: Monitored monthly by a licensed clinical professional (physician, physician assistant, nurse practitioner, licensed/registered dietitian)
Supervised by commercial program staff (Weight Watchers, Jenny Craig, etc.)
Self-Monitored

1) Name/type of diet: ______

Dates diet practiced (month/year): ____/_____ to ____/_____ (# of months: ______)

Beginning weight: ______Pounds lost: ______Pounds gained: ______

Supervision: □ Medically□ Licensed/Registered Dietitian□ Commercial Program□ Self

2) Name/type of diet: ______

Dates diet practiced (month/year): ____/_____ to ____/_____ (# of months: ______)

Beginning weight: ______Pounds lost: ______Pounds gained: ______

Supervision: □ Medically□ Licensed/Registered Dietitian□ Commercial Program□ Self

3) Name/type of diet: ______

Dates diet practiced (month/year): ____/_____ to ____/_____ (# of months: ______)

Beginning weight: ______Pounds lost: ______Pounds gained: ______

Supervision: □ Medically□ Licensed/Registered Dietitian□ Commercial Program□ Self

4) Name/type of diet: ______

Dates diet practiced (month/year): ____/_____ to ____/_____ (# of months: ______)

Beginning weight: ______Pounds lost: ______Pounds gained: ______

Supervision: □ Medically□ Licensed/Registered Dietitian□ Commercial Program□ Self

Dietitian Assessment:

Food allergies or restrictions:______

Vitamins and herbal supplements:______

History of eating disorders: ______

Diet and Weight-Loss History

Weight 1-year ago: ______

Lowest adult weight: ______Age at that weight: ______

Highest adult weight: ______Age at that weight: ______

Was there a specific event or set of events that corresponded with your weight gain? (Overweight since childhood; gained weight after an injury; gained weight after pregnancy) ______

Which weight-loss plan(s) worked best for you, and why? ______

Weight loss surgery goals, why are you interested in weight loss surgery? ______

______

Weight-loss medications:

Medication / Dates Taken / Amount of Weight Lost / Amount of Weight Regained / Duration of Weight Loss
Xenical (Alli, Orlistat)
Meridia (Subutramine)
Phen-fen
Redux
Other

Occupation: ______Any travel involved? Y / N how much ______

Day-to-day Schedule: (work hours if applicable): ______

______

Does your schedule affect eating and lifestyle behavior? If yes, please list how: ______

Who does the shopping and cooking: □ me □ spouse □ other

Are there other people in the home, please list:

______

Meals eaten outside of home (frequency and location): ______

≤3 times/week3-5 times/week5-10 times/week>10 times/week

List any frequent cravings: ______

Beverage consumption, please list what you drink and how much daily:

Coffee / Tea / Juice / Soda/pop / Water / Milk / Other
Amount

24 hour recall, please list everything you ate and drank yesterday for the whole day plus quantity or amount eaten:

______

I certify that the information I have provided is correct and complete to the best of my knowledge.

Signature: ______Date: ______

I have reviewed the preceding health history.

Physician’s Initials: ______Date: ______