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Medical History Questionnaire

Please complete this questionnaire. Do not leave any questions blank. If the question does not apply, please answer with “NA.”
* Required Fields.

Date:
Current Height:
Current Weight:
*Name: (First,Last)
Age:
Date of Birth:
Address:
City:
State:
Zip Code:
Phone Number (Home):
Phone Number (Work):
Phone Number (Cell):
Race:
Sex:
E-mail Address:
Your Occupation:
Your Employer Address:
Insurance Company:
Policy Number:
Insurance Phone #:
Group Number:
Insurance Company:
Policy Number:
Insurance Phone #:
Group Number:
Spouse Name:
Spouse Occupation:  
Spouse Employer Address:  
Name and Address of Physician:  
Other Physicians Seen Recently:  
Interested In:  
Medical
Gastric By-Pass Surgery
Lap Band Surgery
Preferred Surgeon:
Seminar Date Attended:

The Center for Weight Management accepts cash, private insurance and Medicare for Gastric bypass, Lap Band and Gastric Sleeve procedures.
If you have insurance, that information will be requested as well. However, you may want to call your insurance to determine coverages and or exclusions.

Previous attempts at weight reduction

How many years have you been overweight?

Diet programs and supplements:
Please indicate which of the following diets or plans you have attempted.

Program
Dates
Duration
MD Supervised?
Weight Loss
Weight Watchers        
Jenny Craig        
Metabolife        
Medifast        
Nutri/System        
Atkins Diet        
Herbalife        
SlimFast        
Grapefruit Diet        
Liquid Diets        
Pritikin Diet        
Optifast        
T.O.P.S.        

List any other physician-supervised weight loss attempts:

Weight-Loss Medication History: Please indicate if you have taken any of the following medications to lose
weight.

Medication
Dates
Duration
MD Supervised?
Weight Loss
Meridia (Sibutramine)
Phen-Fen
Amphetamines
Phentermine (Adipex,
Fastin, Pondimin)
Dexfenfluramine (Redux)
Xenical (Orlistat)
Other Diet Medications:

Non-Dietary Therapies: Please indicate if you have tried any of the following weight loss therapies:

Therapy
Dates
Duration
MD Supervised?
Weight Loss
Exercise
Hypnosis
Behavior Modification
Acupuncture


List any other weight loss methods you have tried:

Previous Weight Loss Surgery:
Yes
No

Surgery Type
Date
Surgeon
Weight Loss

Please bring a chronological diet history to your initial appointment (a 3 or 7 day diary).

Obesity Related Medical History:
Do you, or have you had, any of the following illnesses or symptoms?

Yes
No
Heart Disease  
If Yes, year of diagnosis:
Angina  
M.I. (heart attack, myocardial infarction)  
Coronary bypass surgery  
Palpitations (abnormal heart beat)  
Heart valve problems  
Pulmonary hypertension  
Congestive Heart Failure  
If Yes, year of diagnosis:
High Blood Pressure  
If Yes, year of diagnosis:      
Elevated Cholesterol  
Elevated Triglycerides  
If Yes, year of diagnosis:      
Diabetes  
If Yes, year of diagnosis:      
Juvenile onset  
Gestational (Pregnancy)  
Adult onset  
Diet controlled  
Oral Medications  
Insulin  
Asthma  
If Yes, year of diagnosis:    
Shortness of Breath - If yes, can you:  
Walk (blocks)    
Climb (flights of stairs)    
Sleep Apnea  
If Yes, do you use a CPAP or BiPAP machine?  
Have you had corrective surgery?  
Has someone told you that you
stopped breathing while sleeping?
 
Sleep Difficulties: Snoring
  Awakenings at night
  Daytime drowsiness
  Observed apnea spells
  Morning headaches
Reflux/Heartburn/Esophagitis/Hiatal Hernia  
If Yes, year of diagnosis:    
Prescription medications:  
Over the counter meds:  
Frequency of use:    
Endoscopy:  
Venous Stasis  
Leg or ankle swelling/edema  
Leg ulceration  
Leg skin color change or thickening  
Pain or Arthritis of Ankles/Knees/Hips  
Limits ability to walk or exercise  
Prescription medications  
Over the counter medications  
Low Back Pain/Sciatica  
Limits ability to walk or exercise  
Prescription medications  
Over the counter medications  
Urinary Incontinence (leakage of urine)  
With coughing/sneezing/straining  
Number of times per week:
Migraine Headaches  
Frequency:    
Prescription medications  
Over the counter medications  
Deep Venous Thrombosis
(Blood clots in legs)
 
If Yes, year of diagnosis:    
Pulmonary embolism  
Blood thinning medication  
Abdominal Wall Hernia  
Incisional  
Umbilical (belly button)  
Number of hernia repairs and dates:    
Hernia currently present  

Past Medical History:

Please list all other medical conditions or illnesses not previously mentioned:

Please list all nonsurgical hospitalizations you have experienced as an adult:

Indication
Hospital
Date

Past Surgical History:
Please list all surgical procedures or operations.

Procedure
Reason
Hospital
Date

Do you have allergies to any medications?

Yes
No

If Yes, please list medications and reactions (e.g., rash, breathing difficulty, shock, etc.)

Yes
No
Have you ever received a blood transfusion?
Have you ever had hepatitis?
Have you ever been exposed to HIV/AIDS
Have you ever abused intravenous drugs?

Medications: Please list all medications you currently use, including “over the counter” medications, herbal
remedies, and dietary supplements.

Name of Medication
Dosage/Frequency
Reason

Family History:

Please indicate if your family members have had any of the following illnesses:

 
Yes
No
Obesity
High Blood Pressure
Heart Disease
Stroke
Lung disease or emphysema
High Cholesterol
Breast Cancer
Other Cancers
Kidney Disease
Diabetes
Blood Disorder
Bleeding Tendency
Is your mother still alive?
If not, please provide the cause of death and age at death.
Is your father still alive?
If not, please provide the cause of death and age at death.

Social History:

Marital Status:

Single Married Separated Divorced

Children:

Yes No Number

Occupation

*Do you use tobacco?

If Yes:

Cigarettes:

Number packs per day: Years of tobacco use:

Cigars:

Number packs per day: Years of tobacco use:

Pipes:

Number packs per day: Years of tobacco use:

Smokeless

Number packs per day: Years of tobacco use:

Do you use alcohol?

Yes No Amount and Frequency:

Do you use drugs?

Yes No Amount and Frequency:

Have you ever been treated for depression?

Yes No

Are you currently in treatment?

Yes No
If Yes, please indicate the name of your physician or therapist:

Have you ever been hospitalized for mental illness?

Yes No

System Review:
Please check any of the following you experience or have experienced in the past.

General

Fever Fatigue
General Weakness Tiredness
Memory Loss Recent Weight Loss
Easy Bruising Night Sweats
Diabetes Abnormal Bleeding
Other

Head and Neck

Trouble with vision Trouble with ears Sinus trouble
Persistent hoarseness Severe headaches Dizziness
Vertigo Loss of smell Sore throat
Difficulty swallowing Pain when swallowing Lump in neck
Other    

Chest, Heart, Lungs

Shortness of breath Poor exercise tolerance Chest pain or pressure attacks
Fluttering of heart Frequent cough Wheezing
Coughing up blood Swollen ankles Night sweats
Heart attack Pain in arms or neck Heart pounding
Palpitations Heart murmur Abnormal heart beats
Low blood pressure Stroke Cold feet
Pain in legs Asthma Loss of pulses
Emphysema Pneumonia Bronchitis
Difficulty sleeping flat Waking at night short of breath  
Other    

Gastrointestinal

Poor appetite Indigestion or heartburn Difficulty swallowing
Nausea or vomiting Vomiting blood Abdominal pain or cramps
Abdominal swelling Diarrhea Constipation
Change in bowel habits Pass blood from rectum Black, tar-like bowel movements
Jaundice Hepatitis Cirrhosis
Heartburn Abdominal pain Pain with bowel movements
Change in stool size Hemorrhoids Irritable bowel
Colitis Other


Kidney

Kidney stones Blood in urine Pain/burning while urinating
Difficulty passing urine Difficulty controlling urine Getting up at night to urinate
Frequent urination Leakage of urine Kidney infection
Bladder infection Irregular periods Pelvic examination/PAP smear within past year
Other    


Bones/Joints

Weakness in arm or leg Painful joints Gout
Loss of muscle strength Swollen joints Back pain
Lump or swelling in muscle Arthritis Muscular aches
Pain in knees Pain in hips Pain in feet
Pain in ankles Sciatica Low back pain
Numbness in feet or legs Herniated disk Abnormal lumps or masses
Other    

Endocrine

Hyperthyroid Low thyroid Goiter
Previous radiation Diabetes Adrenal gland tumor
Swollen glands Cold when others are not Hot when others are not
Persistent thirst Previous steroid (corticosteroids, cortisone) use or injections
Other  

Skin

Changing mole Rash Burns
Skin cancer Other  


Neuromuscular

Seizures Convulsions Fainting
Dizziness Light headedness Falling
Muscle weakness Numbness Tremors
Loss of consciousness Strokes
Other  

Psychological

Depression Nervousness Suicidal thought
Suicide attempts Schizophrenia Anorexia
Bulimia Binge eating  
Hospitalization for emotional problems Psychiatric or psychological counseling  
How do you find your life? Unsatisfactory Boring
Satisfactory Other
Do you: Cry easily Have difficulty with sleep
Feel anxious or upset  
Other    


Women

Breast lump Discharge from nipple Hot flashes
Possibly pregnant Irregular periods Mammogram within past year
Vaginal discharge Vaginal bleeding or spotting (not w/periods)
Other  


Men

Prostate trouble Discharge from penis Sore on penis
Lump in testicles Difficulty having erections
Other  

 

UTMB Center for Obesity and Metabolic Surgery, 2240 Gulf Freeway South, League City, Texas 77573
(832) 505-1500   obesity.center@utmb.edu

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