new patient health questionnaire€¦ · the weight loss surgery center 16 hospital road plymouth,...

The Weight Loss Surgery Center 16 Hospital Road

Plymouth, NH 03264 Phone: 603-536-5670

FAX: 603-536-1544

New Patient Health Questionnaire

If you have questions, please contact: Lauren Sirignano, RN, BSN

Nurse Coordinator for Plymouth General Surgery a department of Speare Memorial Hospital

16 Hospital Road Plymouth, NH 03264 603-536-5670 x528

[email protected]

New Patient Health Questionnaire 1

The Weight Loss Surgery Center 16 Hospital Road

Plymouth, NH 03264 603-536-5670

FAX: 603-536-1544

Welcome to the Weight Loss Surgery Center (WLSC) at Plymouth General Surgery and Speare Memorial Hospital. The WLSC is a coordinated effort by Speare Memorial Hospital to provide patients with access to metabolic and bariatric surgery. We strive to prolong life by helping to control medical conditions that result from obesity through surgical intervention, education, behavioral modification and lifelong support for our patients.

The WLSC team looks forward to working with you and getting to know you better throughout your journey to wellbeing. We use a multidisciplinary approach and utilize bariatric surgeons, primary care providers, nurses, dietitians, exercise physiologists and behavior health specialists to help determine how to create the best and safest outcomes for our patients. We also work closely with specialists and our WLSC staff will refer patients to other providers when deemed necessary.

Weight management is a lifelong journey and we believe that in order to be successful, you must agree and commit to changes in lifestyle and behavior both before and after weight loss surgery. These modifications are imperative to long-term success with weight loss, regardless of the approach. Throughout your time with us we hope to educate and inspire positive change that encourages you to become dedicated to your lifelong health and wellness ambitions.

Thank you for attending the information session regarding weight loss surgery. Enclosed you will find forms and steps that will need to be completed prior to consulting for weight loss surgery with one of our surgeons. Towards the end of the packet you will see a patient checklist. This checklist will be very helpful when organizing documents and scheduling necessary appointments pertaining to weight loss surgical clearance. Please note the patient contract found in the pre-operative packet. We ask that our patients sign this contract, along with the practitioners that will be involved in their care, verifying a mutual understanding of what will be required to ensure the best surgical outcomes possible for our patients. The pre-operative packet will be reviewed in detail prior to signing the patient contract at the time of consult.

Please be sure to contact our office with any questions as you begin to navigate the program and obtain the documents necessary for weight loss surgery clearance. Also, please remember that everyone has a different journey through the weight loss surgery process and please expect a minimum of five to six months in our program prior to weight loss surgery. We are here to help guide you and to ensure that patients receive the best and safest care possible.

Sincerely,

James P. Koren, M.D, Weight Loss Surgery Center Director Lauren Sirignano, RN, BSN, Weight Loss Surgery Center Program Coordinator Janette Gaumer, RD, LD, Weight Loss Surgery Center Registered Dietitian Robert J. Chastanet, M.D, Weight Loss Surgery Center Bariatric Surgeon Weight Loss Surgery Center at Plymouth General Surgery Department of Speare Memorial Hospital


Today’s Date ______________

Patient’s Name (First/Last) _______________________________________ Date of Birth _________________

INSURANCE REQUIREMENTS

Prior to surgical consult, patients are required to contact their insurance company and verify that office visits and surgical treatment for morbid obesity are a covered benefit specific to their plan. Patients are also required to request their insurance company to mail AND email the patient a copy of their policy, specific to weight loss surgery. It is not uncommon for patients to need additional testing and/or clinician visits not covered by the insurance provider. Patients are responsible for knowing what their insurance company will and will not cover. Any expenses not covered by the insurance provider are the responsibility of the patient. Codes the insurance company may request:

Gastric Bypass (Roux-en-y) 43644

Gastric Sleeve 43775

All insurance companies have specific requirements patients need to meet prior to obtaining prior authorization for weight loss surgery. On average, insurance companies require 3-6 months of participation in a supervised weight loss regimen before they will consider authorization for weight loss surgery. Our program also has specific requirements and clearances that patients will need to meet (separate from insurance requirements) before weight loss surgery.

Primary Insurance Name(s) ________________________________________________________________________________

Policy Number __________________________________________________________________________________________ Policyholder's Name _____________________________________________________________________________________ Group Number _________________________________________________________________________________________ Relationship to Policyholder _______________________________________________________________________________ Policyholder's Date of Birth _______________________________________________________________________________ Policyholder's Employer __________________________________________________________________________________ Insurance Company Address ______________________________________________________________________________ Insurance Company Phone Number _________________________________________________________________________

Secondary Insurance Name(s) _____________________________________________________________________________

Policy Number _________________________________________________________________________________________ Policyholder's Name ____________________________________________________________________________________ Group Number ________________________________________________________________________________________ Relationship to Policyholder ______________________________________________________________________________ Policyholder's Date of Birth _______________________________________________________________________________ Policyholder's Employer _________________________________________________________________________________ Insurance Company Address _____________________________________________________________________________ Insurance Company Phone Number_________________________________________________________________________

*Insurance Identification*


Today’s Date _______________

PATIENT INTAKE- please print clearly

Patient’s Name ______________________________________ Date of Birth _________________

Gender (as it appears on your birth certificate) Male Female

Phone (Home) ___________________ (Cell) __________________ Email Address_________________________________

Okay to contact you via email? Yes No

Home Address _____________________________________________________________________________________

Primary Language Spoken

English Spanish American Sign Language Mandarin French Other________________

Emergency Contact (Name) _____________________________ (Relationship) _______________ (Primary Phone #) _______________

Primary Care Physician (Name) ________________________________ (Phone) ______________________ (Fax) ____________

(Address) ___________________________________________________________________________________________

Have you seen your PCP in the last 6 months? Yes No *required prior to consult

Have you obtained a referral for weight loss surgery from your PCP? Yes No *required prior to consult

Primary Pharmacy Used (Name) ________________________________ (Phone) ______________________ (Fax) _______________

(Address)_______________________________________________________________________________

Specialist Physician Past and Current (sleep medicine, cardiology, pulmonologist, endocrinologist, etc.)

(Name and Specialty) ________________________________ (Phone) ______________________ (Fax) _______________

(Address)_______________________________________________________________________________

(Name and Specialty) ________________________________ (Phone) ______________________ (Fax) _______________

(Address)_______________________________________________________________________________

(Name and Specialty)________________________________ (Phone) ______________________ (Fax) _______________

(Address)_______________________________________________________________________________

(Name and Specialty)________________________________ (Phone) ______________________ (Fax) _______________

(Address)_______________________________________________________________________________

Employment Status

Full Time Part Time Unemployed Retired

Employment title (if employeed) ______________________________________

Weight Loss Surgery Center-Preferred Surgeon

Dr. James Koren Dr. Robert Chastanet No Preference/Unknown

*New Patient Intake Form*


Today’s Date _______________


Surgeries Offered by the Weight Loss Surgery Center

Roux-En-Y Gastric Bypass and Sleeve Gastrectomy

SIMILARITIES

No foreign bodies needed to during surgery, which in turn means lower risk for

complications when compared to other weight loss surgeries

Roux-En-Y and Sleeve Gastrectomy will both decrease appetite

Both weight loss surgery methods decrease the hormone ghrelin, also known as

the “hunger hormone” ghrelin plays a role in regulating appetite

In regards to long-term outcomes; both methods (and all methods) of weight loss,

are largely dependent on behavior modification, including diet and exercise habits

Roux-En-Y Gastric Bypass and Sleeve Gastrectomy

DIFFERENCES

Dumping Syndrome possible with the Roux-En-Y method

Roux-En-Y has risks of malabsorption post-operatively, especially if diet and

recommended follow up are not adhered to, this can also result in anemia

There is longer standing research and evidence of success with the Roux-En-Y

making it the gold standard for weight loss surgery

Sleeve Gastrectomy can make GERD (acid reflux) much worse and there for is not

recommended in patients with a significant history

Roux-En-Y is potentially reversible, unlike the Sleeve Gastrectomy

Gastric ulcers are more likely with the Roux-En-Y; especially in patients who use

nicotine, drink alcohol regularly or in excess or take Aspirin/Advil/Motrin


Today’s Date _______________


Which surgery are you currently considering?

Roux-En-Y

Sleeve Gastrectomy

Undecided

*Health History Questionnaire*

ROUX-EN-Y GASTRIC BYPASS

Before After

SLEEVE GASTRECTOMY

Before After


Today’s Date _______________

PATIENT HEALTH QUESTIONNAIRE- please print clearly


Current Weight: ___________ Current Height: ___________ Current BMI: ___________


How to calculate your BMI

Devised in the 1830’s by a mathematician the formula for calculating your BMI is as follows:

Imperial:

BMI= 703 x weight (in lbs) ÷ (height in inches)2

Metric:

BMI= weight (in kg) ÷ (height in meters)2


Today’s Date _______________

PATIENT HEALTH QUESTIONNAIRE CONTINUED- please print clearly

Patient’s Name ______________________________________ Date of Birth ______________

WEIGHT LOSS HISTORY

Most insurance companies require detailed, documented evidence of previous attempts at weight loss, and it may be imperative for obtaining insurance approval. It is critical that you fill this section out thoroughly; please include dates and length of time each strategy was attempted. If the attempt at weight loss was supervised (MD, RD, RN, etc.) please include information on facility that supervised attempt:

Previous Attempts at Weight Loss Time in Program/Approx. Dates/Weight Lost

1) Low Carbohydrate Diet/Atkins ____________________________________________________

2) High Protein Diet ____________________________________________________

3) Low Fat Diet ____________________________________________________

4) Calorie Restrictive Diet ____________________________________________________

5) Optifast/Slim Fast/shake program ____________________________________________________

6) Weight Watchers ____________________________________________________

7) Dietitian ____________________________________________________

8) Nutri-System ____________________________________________________

9) Body for Life (Bill Phillips) ____________________________________________________

10) Jenny Craig ____________________________________________________

11) Overeaters Anonymous ____________________________________________________

12) Diet Pills (type) ____________________________________________________

13) MyFitnessPal (or other tracker) ____________________________________________________

14) Hypnosis ____________________________________________________

15) Other ____________________________________________________

Have you ever participated in a weight loss surgery program? Yes No

If yes, provide more detail (when, where, and why did you leave the program?)__________________________________________

__________________________________________________________________________________________________________

How did you hear about the Weight Loss Surgery Center? ___________________________________________________________ ___

______________________________________________________________________________________________________________

What are your biggest concerns or worries as you begin the road to weight loss surgery? _____________________________________

_____________________________________________________________________________________________________________

What is the most you have ever weighed? Weight: _______________ Date:_____________________

How long have you been overweight?

All my life (childhood) Adolescence (teenager/high school) Adulthood After pregnancy

Since an event (explain further) ____________________________ Other _______________________

Who do you generally cook/eat with? ______________________________

Do you feel that they supportive of your weight loss goals? Yes No

Explain further: __________________________________________________________________________________________



Today’s Date _______________



MEDICAL HISTORY

ALLERGIES

Do you have any allergies to medicine? Yes No

If yes, list medication, reaction, date of reaction____________________________________________________________

Do you have any allergies to food? Yes No

If yes, list food, reaction, date of reaction _________________________________________________________________

Have you ever had a reaction to anesthesia? Yes No

If yes, explain in detail_________________________________________________________________________________

Has anyone in your family ever had a reaction to anesthesia? Yes No

If yes, explain in detail_________________________________________________________________________________

CARDIOVASCULAR

Heart problems Chest Pains Previous heart attack High blood pressure

History of blood clots Shortness of breath High cholesterol Fatigue issues

Palpitations Arrhythmia/ablation Pacemaker or Defibrillator Heart Failure

Coronary Artery Disease (CAD) Other

If yes to any of the above, explain further in detail (include MD info that treated you) _______________________________________

____________________________________________________________________________________________________________

ENDOCRINE (diabetes, thyroid, etc.)

Diabetes Mellitus (if yes, circle one) Type 1 Type 2

Do you take medication (Insulin, Metformin, etc)? Yes No

If you take medication, what do you take? ____________________________________

Have you ever managed your diabetes with weight loss or diet? Yes No

If yes, explain further in detail____________________________________________________

Last HgbA1C (date) __________________ (result) ____________________________________

Hypothyroid (or other issues with thyroid) Yes No

If you take medication, what do you take? ____________________________________

MUSCLUSKELETAL

Do you have a history of osteoarthritis or other forms of arthritis? Yes No


Do you ambulate with an assistive device? Yes No


Are you using anti-inflammatory or pain medication? Yes No


Do you experience pain daily? Yes No




Today’s Date _______________


Patient’s Name ______________________________________ Date of Birth _______________

GASTROINTESTINAL (GI)

Gallbladder

Have you ever had gallstones? Yes No

Do you still have your gallbladder? Yes No

Ulcers/Acid Reflux (GERD)

Have you ever taken medicine for ulcers? Yes No

If you take medication, what did/do you take? ____________________________________

Have you ever been diagnosed with H.pylori? Yes No

If yes, did you take antibiotics and when? ____________________________________

Do you currently, or have you ever, taken medication for GERD (acid reflux)? Yes No

If you take medication, what did/do you take? ____________________________________

Abdominal Surgeries

Have you ever had surgery on your abdomen or colon? Yes No

If yes, what did you have done, where was it done and when? ____________________________________

Other GI History

Do you have any other GI history not mentioned (i.e. colitis, diverticulitis, IBS, etc.)? Yes No


RESPIRATORY

Asthma COPD Recurrent Bronchitis

Pneumonia Anesthesia complications history Blood clots in lungs/legs (PE/DVT)

Tuberculosis Acute Respiratory Distress Other

If yes to any of the above, explain further in detail (include MD info that treated you) _______________________________

____________________________________________________________________________________________________________

________________________________________________________________________________________________________

Smoking History

Have you EVER smoked tobacco (in any form)? Yes No

If yes, length of time? ____________________________________________

If you no longer smoke, when did you quit? How long did you smoke for? _____________________________

Do you CURRENTLY smoke? Yes No

If yes, how much do you smoke on a daily basis? ____________________________________________________

If yes, have you ever attempted to quit? How? ______________________________________________________

Are you willing to quit smoking and take nicotine lab tests prior to surgery? Yes No

Are you able to walk up a flight of stairs without stopping? Yes No

Are you able to walk up a flight of stairs without running out of breath? Yes No



Today’s Date _______________


Patient’s Name ______________________________________ Date of Birth _____________

Sleep Apnea

Have you ever had a sleep study or do you currently have one scheduled? Yes No

If yes, who do you see for sleep medicine? _________________________________________

When were you last seen/when will you be seen next? ____________________________________________

Do you now, or have you ever used a CPAP or BiPAP machine? Yes No

If you have a diagnosis of OSA, and have not been cleared by your sleep medicine doctor, are you compliant with your CPAP machine? Yes No

STOP-Bang Questionnaire

Please answer yes or no to the following questions:

Snoring? Do you SNORE LOUDLY (loud enough to be heard through closed doors or your bed-partner

elbows you for snoring at night)? Yes No

Tired? Do you often feel TIRED, FATIGUED, OR SLEEPY during the daytime (such as falling asleep during

driving or talking to someone)? Yes No

Observed? Has anyone OBSERVED you STOP BREATHING or CHOKING/GASPING during your sleep?

Yes No

Pressure? Do you have or are you being treated for HIGH BLOOD PRESSURE?

Yes No

Body Mass Index? Is your BMI MORE THAN 35?

Yes No

Age? Older than 50 YEARS OLD?

Yes No

Neck size LARGE? (Measured around Adams- apple)

For male, is your shirt collar 17 inches/43 cm or larger?

Yes No

For female, is your shirt collar 16 inches/41 cm or larger?

Yes No

Gender = Male?

Yes No

Depending on score, once tallied by WLSC clinician, referral to sleep medicine from PCP may be required prior to surgery



Today’s Date _______________



KIDNEY AND BLADDER

Do you have renal failure/insufficiency? Yes No

Have you had frequent kidney stones, kidney infections and/or issues with your kidneys or bladder? Yes No

OTHER

Do you have any autoimmune diseases or issues? Yes No

If yes, explain further in detail___________________________________________________________________________

Have you ever had an organ transplant or been on a transplant list? Yes No


Have you ever had a blood transfusion, or experienced a bleeding problem? Yes No


Have you ever had cancer or other diagnoses not previously mentioned? Yes No


SURGICAL HISTORY

List ALL previous surgeries (include date, and facility surgery took place)

1) __________________ 2) __________________ 3) __________________

4) __________________ 5) __________________ 6) _________________

NEURO/PSYCHIATRIC

Have you ever been treated for, diagnosed with, or taken medication for any of the following:

Depression Anxiety Bipolar Disorder Schizophrenia

PTSD Alcohol Abuse Bulimia Anorexia

Binge Eating Disorder Seizures Suicidal Ideation Psychosis

If yes to any of the above, explain further in detail (include MD seen, medication taken, etc.) _______________________________

____________________________________________________________________________________________________________

________________________________________________________________________________________________________



Today’s Date _______________



MEDICATIONS

(List ALL medications currently taking including any over the counter medications and supplements)

NAME DOSE FREQUENCY REASON FOR TAKING

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

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new patient health questionnaire€¦ · the weight loss surgery center 16 hospital road plymouth,...

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