Bariatric Program Application Form | Bariatric Surgery

1 Patient Information
2 Responsible Party Information
3 Hospital History
4 Medical History or Symptoms
5 Medication Log
6 Consent To Contact

Patient Information

Patient's First Name ^*

Patient's Last Name ^*

Race

Gender:

Male

Female

Date of Birth

Age

Street Address

City

State

Zip Code ^*

Home / Cell Phone

Please enter phone number without dashes (ex. 9017651000)

Work Phone

Please enter phone number without dashes (ex. 9017651000)

Marital Status

Married

Single

Divorced

Widowed

Patient's Occupation

Employer's Name

Email Address ^*

Primary Care Physician ^*

Pharmacy

Pharmacy Telephone Number

Please enter phone number without dashes (ex. 9017651000)

How did you hear about our program? ^*

Referring physician

Family or Friend referral

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Online Search

Social Media Ad

Other...

Mobility needs

Do you have any mobility restrictions?

Are you in a wheelchair?

Do you use a scooter?

Would you need to be transported by stretcher to an appointment?

Previous step

1 Patient Information
2 Responsible Party Information
3 Hospital History
4 Medical History or Symptoms
5 Medication Log
6 Consent To Contact

Responsible Party Information

Relationship to Patient ^*

First Name

Last Name

Date of Birth

Street Address

City

State

Zip Code

Home Phone

Please enter phone number without dashes (ex. 9017651000)

Work Phone

Please enter phone number without dashes (ex. 9017651000)

Employer

Insurance Information - A Copy of your insurance Card(s) - Front and Back - Is Required.

Select Insurance Preference ^*

First Insurance

Insurance Company Name

Policy Number

Group Number

Phone Number

Please enter phone number without dashes (ex. 9017651000)

Policy Holder

Date of Birth

Second Insurance

If you do not have a second insurance, please do not complete this section.

Insurance Company Name

Policy Number

Group Number

Phone Number

Please enter phone number without dashes (ex. 9017651000)

Policy Holder

Date of Birth

In Case of Emergency Notify (Other Than Responsible Party)

Name

Select a choice

Address same as patient.

Street Address

City

Zip Code

State

Phone Number

Please enter phone number without dashes (ex. 9017651000)

Previous step

1 Patient Information
2 Responsible Party Information
3 Hospital History
4 Medical History or Symptoms
5 Medication Log
6 Consent To Contact

Hospital History

Please list any hospital stays you have had

First Event

Previous Hospitalizations/Surgeries/Serious Illnesses

Date

Second Event

Previous Hospitalizations/Surgeries/Serious Illnesses

Date

Third Event

Previous Hospitalizations/Surgeries/Serious Illnesses

Date

Have you had previous weight loss surgery?

Yes

Do you have an abdominal mesh from a previous surgery?

Yes

Have you or any of your family members had any type of problem with anesthesia?

Yes

Weight History

Current Height ^*

Current Weight ^*

How much weight do you expect to lose?

Which procedure do you prefer?

Roux-en-Y Gastric Bypass:

Sleeve Gastrectomy:

Converting from Band:

Previous step

1 Patient Information
2 Responsible Party Information
3 Hospital History
4 Medical History or Symptoms
5 Medication Log
6 Consent To Contact

Medical History or Symptoms

Review of Symptoms: Please indicate any personal medical history below:

Genitourniary

Kidney Stones

Kidney Failure

Incontinence or Dribbling

Leakage of urine with coughing laughing or sneezing

On Dialysis

None

Psychological

Anxiety

Depression

Hospitalization for emotion problem.

None

Neurological

Stroke

Dizziness, vertifo.

Numbness, tingling feelings, weakness.

Tremors

Convulsions/Seizures

Loss of consciousness.

Pseudotumor Cerebri.

None

Endocrine

Thyroid Disease

Diabetes

Adrenal Gland Tumor

PCOS

None

Musculoskeletal

Pain/Swelling in Joints

Degenerative Join Disease

Arthritis

Low back pain / back injury

Ankle and foot pain

Joint Replacements

Fibromyalgia

Multiple Sclerosis

None

Other Conditions

HIV / AIDS

Bleeding disorder

Blood clotting disorder

On Blood thinners / steroids

History of Blood Clots

Other...

Other Conditions we should be aware of?

Previous step

1 Patient Information
2 Responsible Party Information
3 Hospital History
4 Medical History or Symptoms
5 Medication Log
6 Consent To Contact

Medication Log

Allergies to Medications:

Allergies to Food:

Latex or Other Allergies:

Please include Medication and Dosage

Pharmacy's Name, Location, and Phone Number

Previous step

1 Patient Information
2 Responsible Party Information
3 Hospital History
4 Medical History or Symptoms
5 Medication Log
6 Consent To Contact

Consent To Contact

On my home voice mail or answering machine

On my work voice mail or answering machine

On my cell phone voice mail

With persons who answer my home phone

Contact by E-mail:

If Accepted Please Include Email:

I authorize any member of the Center for Surgical Weight Loss staff to release any and all of my medical information to the Medical Director for Surgical Weight Loss Program, Dr. Robert Wegner.

I understand that personal information that is volunteered during group discussions in class and/or seminars will be kept within the group, and will not be repeated.

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Name:

Previous step

Thank you for contacting the Saint Francis Center for Surgical Weight Loss

Patient Information

Responsible Party Information

Insurance Information - A Copy of your insurance Card(s) - Front and Back - Is Required.

First Insurance

Second Insurance

If you do not have a second insurance, please do not complete this section.

In Case of Emergency Notify (Other Than Responsible Party)

Hospital History

Please list any hospital stays you have had

First Event

Second Event

Third Event

Weight History

BMI Calculator

Medical History or Symptoms

Review of Symptoms: Please indicate any personal medical history below:

Medication Log

Medication Log

Consent To Contact