Lap Band Surgery

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The information in this form is an important part of planning your surgical care. Providing incomplete or inaccurate information could result in the delay or cancellation of your surgery as well as jeopardize the ability of the physician to provide the best possible care.

Patient Information
     
First Name   Last Name  
Birth Date   MM / DD / YYYY    
Age   Race  

Address

  City  

State

   Zip  

Home Phone

  Cell Phone   

Email

  Social Security #   

Employer

  Address  
Occupation   Phone  
City   State       Zip: 
           

 

 

Emergency Contact Information
           

Name

  Relationship   

Phone

  Address   

City

  State       Zip 
           

 

 

Insurance Information
           

Insured Name

       Insurance Renewal Date:   

Address

  City  

State

  Zip  
           

Birth Date (mm/dd/yyyy)

  Social Security No  

Employer

      Occupation  

Address

  City  

State

  Zip  

Insurance Company

  Group Number  

Policy Number

             Phone   
           

 

 

Primary Care Physician Information
         
Physician Name   May we send your PCP information about your case? Yes  No
Address   Are you receiving disability benefits? Yes  No

Phone

  Reason for Disability:  

City

 

State

 

Zip

 
 

   I authorize the release of necessary medical information to process my insurance

   claims. I authorize payment of insurance benefits for services rendered to:

   
   Electronic Signature: Date: 

   Parent Signature (if under 18):

Date: 
 
 

 

 

Medical Information
 
Current Weight lbs. Are you a snacker? Yes  No
Current Height Do you eat a lot of junk food? Yes  No 
How long have you been overweight? How often do you eat junk food? / weekly
Age you began first diet? yrs. Favorite foods:
Most weight you ever lost? lbs.
How was weight loss obtained?  
Surgery you are interested in  
Are you currently under a physicians care for weight loss?  Yes  No
If yes, name and address: 
 

List any medical problems you have for which you have seen a doctor or been hospitalized.

 
List: Illness, Date, Treatment, and Outcome
 
 
 

 

 

Medical History
   
Diagnosed or treated for high blood pressure? Chest pain when exercising?
Diagnosed or treated for diabetes? Short of breath at rest?
High blood cholesterol? Short of breath when exercising?
High blood fats or triglycerides? Wake up at night short of breath?
Diagnosed with asthma? Irregular or excessively strong heartbeats?
Diagnosed or treated for GERD? Sleep lying flat?
Stomach ulcers? Blackouts?
Blood clots in your leg veins? Swollen ankles?
Have you ever been anemic? Excessive bleeding from surgery or minor injuries?
Iron deficiency or taken iron? Have you had easy bruising?
Diagnosed with hypothyroidism?

For Women:

 
Ever had thyroid surgery? Heavy periods?
Thyroid replacement medication? Still having periods?
       

 

 

Surgical History
List all surgeries and specify if done open or laparoscopically.

 

List: Surgery, Date and Reason

 

   

   

   

   
Have you had Weight loss surgery before?  Yes No
If Yes when and what type of surgery:
Does your religion prohibit you from receiving blood products?
Have you had your gallbladder removed?7
Have you had a hysterectomy?
Have you had a tubal ligation or had your "tubes tied"?
   

 

 

Medications

List all current medications, including prescriptions, vitamins, over-the-counter, and intermittently used drugs.

Include name, strength, frequency, purpose, and when you first started the medication.

 

 
 
 
 

List any allergies to medication and explain reactions you experienced.

 
Have you ever smoked tobacco products? If yes, how many years? 
How many cigarettes per day? 
Do you currently use tobacco products? If yes, how many per day?
   
 

 

 

Sleep Apnea Self Test
The quiz is designed to alert you to any problems resulting from poor sleep. Please answer the questions below. If you have had any symptoms in the past year, mark the box below and add up the total.

 

Q1  I have been told that I snore or I know that I snore +20 points
Q2 I definitely do not snore -50 points
Q3 I do not know if I snore +0 points
Q4 I have been told that I stop breathing when I sleep +10 points
Q5 I wake up choking +10 points
Q6 I sweat excessively at night +5 points
Q7 (If female and above is true) I have hot flashes related to my cycle -5 points
Q8 I am tired and sleepy during the day even after 8 hours of sleep +2 points
Q9 I wake up tired and unrested +2 points
Q10 I suddenly wake up unable to breathe +10 points
Q11 I have fallen asleep while driving +5 points
Q12 I am a restless sleeper (toss and turn a lot) +5 points
Q13

My neck circumference is more than 17 inches

+20 points
Q14 I frequently have morning headaches. +5 points
       
  Total (more than 30 points suggests that you have SLEEP APNEA.)  
     
  Do you sleep with a C-Pap?
  Do you sleep with a Bi-Pap?
  Have you ever received psychiatric treatment?
  If yes, diagnosis or reason for treatment:
  Last treatment date:
  Treated by: Psychiatrists   Psychologists   Physician
  Physicians Name:
  Address:
  Phone:
     

 

 

Dietary History - Medically Supervised Diets
 
Diet Programs Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.
   
Medi-Fast:
Opti-Fast:
Mayo Clinic:
Physician Diet Program:
   

Shots

Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.
   
B-6:
B-12:
Other:
   

Pills

Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.
   
Lasix (diuretic):
Xenical:
Meridia:
Other:
 
M.D./Clinic Name:
 

 

 

Dietary History - Non-Supervised Diets
Please fill out this section as accurately as possible. List all diets you have tried, how many times you have tried them, how long you were on the diet, and how much weight was lost and regained.

 

  Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.
   
Weight Watchers:
Nutri-System:
Jenny Craig:
Diet Center:
TOPS:
Overeaters Anonymous:
   
Liquid Diets Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.
   
Slim Fast:
Sweet Success:
Liquid Protein:
   
Misc. Diets Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.
   
Low Calorie Diet:
Low Fat Diet:
High Protein Diet:
Self-Imposed Fasting
Richard Simmons:
Herbal Life:
Cambridge Diet:
Atkins Diet:
   
OTC Diet Pills Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.
   
Acutrim:
Dexatrim:
Metabolife:
Xenadrine:
   
Other Weight Loss Methods Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.
   
Psychotherapy:
Acupuncture:
Hypnosis:
Subliminal Tapes:
   
Exercise Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.
   
Health Club:
Exercise Tapes:
Outdoor Activity:
   

 

I have provided complete and accurate information to the best of my knowledge.

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