Submitted by ahs-admin on Wed, 03/23/2022 - 09:30 You must have JavaScript enabled to use this form. Welcome to our practice! We are excited to learn more about you and how we can help you achieve your weight loss goals. Please answer the following questions as accurately as possible. Your surgical team will use your answers to help guide your treatment. First Name * Last Name * Birthdate * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Age * Current Weight (lbs) * Height * Insurance Provider * Insurance ID * For how many years have you struggled with your weight? * What was your highest weight in the last 5 years? * What was your lowest weight in the last 5 years? * What was your weight in high school? * Has anyone else in your family had bariatric surgery? If so, which surgery? * What do you hope to gain from bariatric surgery? * Please indicate which (if any) of the following medical conditions you have been diagnosed with * High blood pressure Coronary artery disease High cholesterol Heart failure Diabetes mellitus Abnormal heart rhythm Obstructive sleep apnea Urinary incontinence Fatty liver disease Infertility or Irregular Menses Gastroesophageal reflux disease Polycystic Ovarian Syndrome Joint or back pain Pseudotumor cerebri Other Other medical conditions Have you or other immediate family members ever developed a venous blood clot (DVT) or pulmonary embolism? * Yes (If so, please provide details) No DVT embolism details Do you have nausea or feel full for many hours after eating? * Yes No Do you suffer from arthritis, fibromyalgia, or other chronic pain conditions? * Do you have irritable bowel syndrome, constipation, or loose stools? * Do you take non-steroidal anti-inflammatory medications (Motrin, Aleve, Naproxen, Voltaren, Mobic), steroids, or prescription pain medications on a routine basis? Please specify which medications and how frequently. * Please indicate current or prior use of each of the following substances. Alcohol Current Alcohol use * No Yes Prior Alcohol use * No Yes Date last used Alcohol MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Cigarettes Current Cigarette use * No Yes Prior Cigarette use * No Yes Date last used Cigarettes MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Tobacco products Current Tobacco use * No Yes Prior Tobacco use * No Yes Date last used Tobacco MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Vaping Current Vaping use * No Yes Prior Vaping use * No Yes Date last used Vape MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Marijuana Current Marijuana use * No Yes Prior Marijuana use * No Yes Date last used Marijuana MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Methamphetamines Current Methamphetamines use * No Yes Prior Methamphetamines use * No Yes Date last used Methamphetamine MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Other drugs Current other drug use * No Yes Prior other drug use * No Yes Date last used Other MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Have you ever been diagnosed with any of the following mental health conditions? * Depression Suicide attempts or hospitalization for mental health illness Anxiety Bipolar disorder Schizophrenia Other None Other mental health conditions Gastroesophageal Reflux Disease Questionnaire (GERD-Q) Please select the option that corresponds to the frequency of symptoms you experience in an average 7 day period. The numbers are added together to calculate your total score Burning feeling behind your breastbone (heartburn) * None 1 day 2-3 days 4-7 days Stomach contents moving back up to your throat or mouth (regurgitation) * None 1 day 2-3 days 4-7 days Pain in the center of the upper stomach * None 1 day 2-3 days 4-7 days Nausea * None 1 day 2-3 days 4-7 days Difficulty getting a good night’s rest because of heartburn and regurgitation * None 1 day 2-3 days 4-7 days Took additional medication for reflux symptoms, other than what was already prescribed by a physician * None 1 day 2-3 days 4-7 days Total Score Do you take prescription medication for acid reflux on a daily basis? * Yes No GERD-Q Assessment Low Likelihood (Total score <3) Moderate Likelihood (Total score 3-7) High Likelihood (Total score >8) STOP BANG Questionnaire for obstructive sleep apnea Your BMI and neck circumference will be measured during your clinic visit. Please answer the remaining questions to the best of your knowledge. If you have already been diagnosed with obstructive sleep apnea and are using a CPAP machine at home, you may skip this portion of the questionnaire. Have you been diagnosed with obstructive sleep apnea and are using a CPAP machine? * Yes No Do you snore loudly? * Yes No Do you often feel tired, fatigued, or sleepy during the day? * Yes No Has anyone witnessed you stop breathing during sleep? * Yes No Have you been diagnosed with high blood pressure? * Yes No Is your body mass index (BMI) over 35? * Yes No Is your age over 50 years old? * Yes No Is your neck circumference over 40 cm? * Yes No Are you male? * Yes No STOP BANG Assessment Low Risk (answering Yes to 2 or fewer questions) High Likelihood (answering Yes to 3 or more questions) Leave this field blank Submit