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Medical History Form

Start your medical history form. This information will be used for the evaluation of your health and to ensure you qualify for weight loss surgery.

The form is extensive, but please try to answer as accurately and completely as possible. Please take your time and complete it carefully and thoroughly, and then, review it to be certain you have not left anything out.

All information will be kept confidential. Fields marked in red are required field.

PERSONAL DATA

*Optional

FAMILY HISTORY

Obesity
Kidney Disease
Heart Disease
Pulmonary Edema
Diabetes
High Blood Pressure
Alcoholism
Liver Problems
Lung Problems
Bleeding Disorder
Gallstones
Mental Illness
Malignant Hyperthemia
Cancer
*Optional

WEIGHT LOSS

Have you ever had surgery for weight loss?
Have you ever seen a doctor about weight loss surgery?
*Optional

MEDICAL HISTORY

Do you have Reflux Disease?
Do you have High Blood Pressure?
Do you have Degenerative Joint Disease?
Do you have Urinary Stress Incontinence?
Do you have High Cholesterol?
Do you have Leg Swelling?
Do you have Irregular Menstrual Periods?
Do you have Diabetes?
Do you use Insulin?
Do you have Sleep Apnea?
Do you use a C-Pap? (if you do please bring it with you for surgery)
Do you use a B-pap? (if you do please bring it with you for surgery)
Do you take medication for depression?
*Optional

SYSTEM REVIEWS

Please indicate if you have or have had any of the following conditions:

Cardiovascular

Heart Attack
Angina (Heart pain with activity)
Rhythm Distrubance/Palpitations
Congestive Heart Failure
High Blood Pressure
Ankle Swelling
Varicose Veins
Hemorrhoids
Phlebitis
Ankle/Leg Ulcer
Heart Bypass/Valve Replacement
Pacemaker
Clogged Heart Arteries
Rheumatic Fever/ Valve Damage
Heart Murmur
Irregular heartbeat
Cramping in the legs when walking
Other Symptoms

Respiratiry

Asthma
Emphysema
Bronchitis
Pneumonia
Chronic Cough
Tuberculosis
Pulmonary Embolism
Shortness of Breath
Hypoventilation Syndrome
Cough Up Blood
Snoring
Sleep Apnea
Lung Surgery
Lung Cancer

Endocrine

Hyperthyroid (low)
Hyperthyroid (high/overactive)
Goiter - Enlarged Thyroid
Parathyroid
Elevated Cholesterol
Elevated Triglycerides
Low Blood Sugar
Diabetes (managed by diet or pills)
Diabetes (managed with insulin shots)
Pre-Diabetes (with elevated blood sugar)
Gout
Endocrine Gland Tumor
Cancer of the Endocrine Gland
High Calcium Levels
Abnormal Facial hair Growth

Gastero-Intestinal

Heartburn
Hiatal Hernia
Ulcers
Diarrhea
Blood in Stool
Changes in Bowel Habit
Constipation
Irritable Bowel Syndrome
Colitis
Crohn's Disease
Hemorrhoids
Fissure
Rectal Bleeding
Black Tarry Stool
Polyps
Abdominal Pain
Enlarged Liver
Cirrhosis/Hepatitis
Gallbladder Problems
Was your Gallbladder Removed?
Jaundice
Pancreatic Disease
Unusual Vomiting
Cancer
Gasterointestinal Surgery

Bladder / Kidney

Kidney Stones
Blood in Urine
Prostate Problems
Kidney Failure
Incontinence urinary
PSA test in the last year?
Burning sensation with urinating?
Trouble Urinating
Surgery on the bladder, kidney or prostate?
Cancer

Musculoskeletal

Arthritis
Neck Pain
Shoulder Pain
Wrist Pain
Back Pain
Hip Pain
Knee Pain
Ankle Pain
Foot Pain
Musculoskeletal Cancer
Heel Pain
Ball of Foot or Toe Pain
Plantar Fasciitis
Carpal Tunnel Syndrome
Lupus
Scleroderma
Sciatica
Autoimmune Disease
Muscle Pain or Spasms
Fibromyalgia
Broken Bones
Joint Replacement
Nerve Injury
Muscular Dystrophy
Prior Musculoskeletal Surgery

Head and Neck

Do you wear contacts or glasses?
Vision Problems
Hearing Problems
Sinus Drainage
Neck Lumps
Swallowing Difficulty
Do you wear Dentures or partials?
Do you have oral sores?
Hoarseness
Head or Neck Surgery
Cancer in the Head or Neck area?

Neurologic

Migrane headaches
Balance Disturbance
Convulsions or Seizures
Weakness
Stroke
Alzheimer
Loss of Vision from High Blood Pressure
Multiple Sclerosis
Have you ever been knocked unconscious?
Do you have frequent severe headaches?
Surgery for Neurologic Disorder
Cancer

Skin

Rashes under skin folds?
Keloids
Poor Wound Healing
Frequent Skin Infection
Surgery for Skin related issues
Skin Cancer

Blood

Anemia (Iron Deficiency)
Anemia (Vitamin B12 deficiency)
HIV
Low Platelets (thrombocytopenia)
Lymphoma
Swollen Lymph Nodes
Superficial Blood Clot in the leg
Deep Blood Clot in the leg
Blood Clot in the Lungs (Pulmonary Embolism)
Bleeding Disorder
Have you received a blood transfusion?
Blood and thinning medication use?

Ginecology
For women only. Men should skip it down to the next section of questions.

Infertility
Are you pregnant?
Uterine/Ovarian Cancer
Surgery?
Menstrual Irregularity?
Menstrual Pain?
Excessively Heavy Periods
Do you plan to have more children?
Are you postmenopausal?

Breast
For women only. Men should skip it down to the next section of questions.

Lumps?
Pain
Fiberocystic disease
Nipple Discharge
Surgery?
Cancer

Psychiatric
All patients (men and women) must answer all questions

Axiety
Depression?
Anorexia (starvation to control weight)
Bulimia (vomiting to control weight)
Bipolar Disorder
Alcoholism
Drug Dependency? (be honest it will not effect your chance of having surgery)
Schizophrenia
Do you have any other psychiatric problems?
Have you ever been hospitalized for psychiatric problems?
Have you ever attempted suicide?
Have you ever been physically abused?
Have you ever been sexually abused?
Have you ever seen a psychiatrist or counselor?
Have you ever taken medication for a psychiatric problem or depression?
Have you ever been in a chemical dependancy program?
*Optional

CONSTITUTIONAL

Fevers
Night Sweats
Anemia
Weight Loss
Chronic Fatigue
Hair Loss

Tabacco use

Do you smoke now?
Do you use snuff or chew?

Alcohol use

Do you drink alcohol now?
Is anyone concerned about the amount you drink?

Caffeine use

Do you drink beverages that contain caffeine?
Do you drink carbonated soda beverages?
*Optional

PAST SURGICAL HISTORY AND MEDICATION

Past Surgical History

*Optional

DAILY DIET

*Optional

PSYCHOLOGICAL GENERAL WELL-BEING INDEX (PGWBI)

This section of the examination contains questions about how you feel and how things have been going with you. For each question select the answer which best applies to you.

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