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Ucla bariatric surgery patient history questionnaire

UCLA BARIATRIC SURGERY PATIENT HISTORY QUESTIONNAIRE
Your appointment will be delayed if this form is incomplete
PLEASE PRINT LEGIBLY
PERSONAL INFORMATION:
Name: __________________________________________________________________ Date: _______________
SSN# (for insurance purposes)_______-______-________ Date of Birth: _________________ Age: __________
Mailing Address: ______________________________________________________________________________
City:__________________________________________ State: ______________ Zip: ______________________
Daytime Phone: _________________________________ Home Phone: _________________________________
Cell phone: __________________________E-Mail Address: __________________________________________
Martial Status: † Single † Married † Divorced † Widowed Gender: † Male † Female
Occupation:____________________________________________ How may hours a week do you work_______

Number of Children
_______ Ages of Children __________________ Do you care for elder relatives________
Who________ What is your involvement in the care_________________________________________________
With whom do you reside?________________________________________________________
How long have you been contemplating bariatric surgery?___________________________________________
Have you done any research regarding bariatric surgery?________
If YES, what type______________________________________________________________________________
How did you hear about this program?____________________________________________________________
Do you have a friend or family member who has had bariatric surgery? ______ Who?____________________
Primary Language Spoken_____________________ Primary Language Reading ________________________
(DO NOT FILL IN: THESE NUMBERS WILL BE OBTAINED AT THE TIME OF YOUR APPOINTMENT)
HEIGHT
Ideal Body Weight
Excess Body Weight
PERSONAL MEDICAL HISTORY: (Do you have or have you ever had. Check all that apply)
Cardiovascular
Gastrointestinal
swollen easily? Do you take medication for the Gynecological
Endocrine
Respiratory
Hematological
getting short of breath? Is it getting worse? Psychological
Surgeries:

Hospitalizations:
TREATMENT

Prescription Medications:
MEDICATION
FREQUENCY

Non-Prescription Medications:
MEDICATION
FREQUENCY

ALLERGIES:
Allergic to any medications
? † Yes † No
Surgical tape: † Yes † No
Latex: † Yes † No
Iodine: † Yes † No If yes, please list medication and reaction:
_____________________________________________________________________________________________
DIETING HISTORY:

Age you first started dieting:_______ Approx. weight at age 18______
Height: ___________ Current Weight: ___________Weight range last 5 years _______ to ________
Duration
MD
supervised?


What was the most successful weight loss you have achieved and how did you do it? _________________________
What behaviors did you learn from dieting that you still use today?_______________________________________
FOOD PREFERENCE:

Are you a sweet eater? † Yes † No If so, what?___________________________________________________
How often?______________________________________________________________________________

Are You a pasta/bread eater?
† Yes † No If so, what?______________________________________________
How often? ______________________________________________________________________________
Are you a fast food eater? † Yes † No If so, what?_________________________________________________
How often? ______________________________________________________________________________
Do you snack between meals? † Yes † No If so, what do you snack on? ______________________________
How often?___________________________________________________________________________________

Is snacking from habit?
† Yes † No Boredom? † Yes † No Do you binge eat? † Yes † No
How often?___________________________________________
What Beverages do you consume throughout the day? _______________________________________________
Quantity? ____________________________________________________________________________________

SOCIAL / FAMILY HISTORY:

Is there Obesity in the family? † Yes † No Who:_______________________________________________
Other medical illness within the family: † Yes † No If so, what: † Diabetes † Hypertension
† Coronary Artery Disease † Other____________________________________________________
Do you exercise regularly? † Yes † No If so, what do you
do:_________________________________________
Do you have any physical restrictions that keep you from exercising? † Yes † No Explain?_____________
_____________________________________________________________________________________________
Have you ever smoked cigarettes / cigars? † Yes † No Do you smoke now? † Yes † No
When did you quit? _______________ How much did you smoke per day?_____________________________
Do you drink alcohol? † Yes † No What type of alcohol do you consume? ___________________________
More than 5 drinks per week? † Yes † No Less than 5 drinks per week? † Yes † No
Have you or are you currently using any recreational/ illegal drugs? † Yes † No
Explain:______________________________________________________________________________________
Do you have a history of abuse? (Please include emotional, physical, mental, substance or other types of abuse
issues you’ve dealt with. This information is extremely important and very confidential. Honesty is needed
in order to provide you with the best possible treatment plan)

Describe your present life stressors:
Describe the present support system you rely upon. (Church, spouse, family, friends, co-workers, etc):

What is your greatest fear regarding the surgery?
What is your greatest hope regarding the surgery?
Why do you (What is motivating) to seek this type of interventions for weight control?
Physicians:
(COMPLETE INFORMATION IS MANDATORY INCLUDING ADDRESS/FAX/TEL)

Specialty
Phone & Fax Numbers
Signature:_____________________________________________________ DATE:_____________

Please return completed form along with a copy of your insurance card and current
authorization (if applicable) to:
UCLA Medical Center
Minimally Invasive Bariatric Surgery Program
Attn: Program Coordinator
Box 956904
Los Angeles, CA. 90095-6904
Fax: (310) 267-4632

Source: http://bariatrics.ucla.edu/workfiles/SurgeryQuestionnaire.pdf

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