Patient name _____________________________________ today’s date ________________

Bariatric Surgery Intake Form
Name ___________________________________________________ Today’s Date _____/_____/_____
Age __________ Date of Birth _____/_____/_____ Phone ( ) x
Referring Physician _____________________________________________________________________
EMERGENCY CONTACT
Name ________________________________________________________
Relationship _________________
Address _______________________________________________________________________
Phone Home
( ) x Work ( ) x
PHYSICIANS
Primary Care Physician ________________________________________________________
Address _______________________________________________________________________
Phone ( ) x Fax ( ) x
Cardiologist (Heart Doctor) ________________________________________________________
Address _______________________________________________________________________
Phone ( ) x Fax ( ) x
Psychologist ________________________________________________________
Address _______________________________________________________________________
Phone ( ) x Fax ( ) x
Psychiatrists ________________________________________________________
Address _______________________________________________________________________
Phone ( ) x Fax ( ) x
Pulmonologist (Lung Doctor) ________________________________________________________
Address _______________________________________________________________________
Phone ( ) x Fax ( ) x
Endocrinologist ________________________________________________________
Address _______________________________________________________________________
Phone ( ) x Fax ( ) x
Orthopedic Surgeon ________________________________________________________
Address _______________________________________________________________________
Phone ( ) x Fax ( ) x
Other Physician ________________________________________________________
Address _______________________________________________________________________
Phone ( ) x Fax ( ) x
Other Physician ________________________________________________________
Address _______________________________________________________________________
Phone ( ) x Fax ( ) x
WEIGHT AND WEIGHT LOSS HISTORY
HEIGHT: ________ feet ________ inches WEIGHT: _______________ pounds
Age of obesity onset:
__________ 0-2 years old __________ 12-18 years old __________ Pregnancy
__________ 2-12 years old __________ Young adult __________ Middle age
How many years have you been at your present weight? ______________________
Greatest single weight loss: ____________ pounds
Weight loss was sustained for: ____________ months
Have you ever been on Phen/Fen (Phentermine/Fenfluramine)? _____ No _____ Yes
If yes, did you take it for longer than six months? _____ No _____ Yes

Please complete the following diet history:
YEAR & LENGTH
NAME OF PROGRAM
OF PARTICIPATION
Weight Watchers
NutriSystem
Pritikin
Scarsdale
Diet Center
Jenny Craig
Dexatrim
Slim Fast
Herbal diets
Richard Simmons
Cabbage Diet
American Heart Association
Radar Institute
Optifast
CareFast
Medifast
Five year weight history:

YEAR WEIGHT
(pounds)
(current year)

Details of any other weight loss measures (including surgical):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

PAST MEDICAL HISTORY (List all hospitalizations and illnesses for which you have been treated,
e.g. diabetes, hypertension, heart disease, lung disorders, etc.):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
MEDICAL HISTORY
Do you have any of the following conditions? (please check)
Diabetes
_____ No _____ Yes (complete section below)
Hypertension _____ No _____ Yes (complete section below)
Sleep apnea _____ No _____ Yes (complete section below)
GERD (reflux disease)
_____ No _____ Yes (complete section below)
Cancer _____ No _____ Yes (complete section below)
Arthritis _____ No _____ Yes
Joint pain
_____ No _____ Yes
Urinary incontinence
_____ No _____ Yes
Elevated cholesterol
_____ No _____ Yes
_____ No _____ Yes
Osteoporosis
_____ No _____ Yes

DIABETES – If you have been diagnosed with or treated for diabetes, please complete the following
section:

Juvenile onset
_____ No _____ Yes Year diagnosed ___________________
Adult onset
_____ No _____ Yes Year diagnosed ___________________

Current form of control:
Diet control only
_____ No _____ Yes
Oral hypoglycemics
_____ No _____ Yes
_____ No _____ Yes Number of injections per day_____

Do you have glycosylated hemoglobin (HBA1C) levels tested? _____ No _____ Yes
If yes, what is your level (if you know) ___________________
HYPERTENSION – If you have hypertension, please complete the following section:

How long have you had hypertension? _______________________________________
Are you taking medication for hypertension? _____ No _____ Yes
SLEEP APNEA – If you have sleep apnea, please complete the following section:

When were you diagnosed with sleep apnea? __________________________________
Do you use C-Pap? _____ No _____ Yes (what settings?) _________________
Do you use Bi-Pap? _____ No _____ Yes (what settings?) _________________
GERD – If you have GERD, please complete the following section:

Do you have reflux during the day? _____ No _____ Yes
If yes, how often?
Many times per day ____ Every day ____ Most days ____ Most weeks ____ Occasionally ____

Do you suffer from heartburn/indigestion during the night? _____ No _____ Yes
If yes, how often?
Many times per day ____ Every day ____ Most days ____ Most weeks ____ Occasionally ____

Does food or fluid reflux in the mouth? _____ No _____ Yes
Do you vomit with reflux? _____ No _____ Yes
Treatments you may use for reflux, heartburn, or indigestion, either prescribed or over
the counter. (check all that apply)
Zantac _____ Tagamet _____ Pepcid _____ Prevacid _____
Nexium _____ Prilosec _____ Surgery _____
CANCER – If you have been treated for cancer, please check all that apply:
Breast _____ Endometrial _____ Prostate _____ Colon _____
Thyroid _____
Skin_____
Blood _____
Other (name) ________________

Year diagnosed ___________ Cancer-free for ______ years
Treatment (check all that apply):
Surgery _____ Chemotherapy _____ Radiation _____ Medication _____
PAST SURGICAL HISTORY:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Any problems with anesthesia? _____ No _____ Yes
If yes, please describe: ___________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Have you had a previous blood transfusion?
_____ No _____ Yes

If yes, date ________________________ reason _____________________________
Have you had a transfusion reaction?
_____ No _____ Yes

If yes, please describe: ______________________________________________________
Will you accept blood products in an emergency?
_____ No _____ Yes

CURRENT MEDICATIONS

Drug Dose
Frequency
Drug Dose
Frequency
ALLERGIES AND ADVERSE REACTIONS (include x-ray dye, antibiotics, skin preps, latex, pain
medications, if applicable):
_______________________________________________________________________________________
_______________________________________________________________________________________
Latex allergy screening questionnaire:
Do you have an allergy to any latex products?
_____ No _____ Yes

Have you experienced local swelling, itching,
or dermatitis associated with latex contact?
_____ No _____ Yes

Do you have a history of wheel or blister
formation on contact with latex products?
_____ No _____ Yes

Have you had an allergic reaction to tape?
_____ No _____ Yes

Have you had any food allergies?
_____ No _____ Yes
If yes, list here: ___________________________________________________________________

FAMILY HISTORY

Health Problems and/or
Alive or Deceased
Cause of Death

Is there a family history of morbid obesity? _________________________________________________
SOCIAL HISTORY (check all that apply)
Marital Status:
_____ Single _____ Married _____ Divorced since ______ _____ Widowed since ______
Number of children: _______
Living Will: _____ No _____ Yes
Tobacco use: _____ None

_____ Currently smoke ____ PPD for _____ years
_____ Previously smoked ____ PPD for ____years, stopped in ______
_____ Smokeless tobacco

Alcohol: ____ None ____ Minimal ____ Moderate ____ Heavy ____ Previously heavy
Caffeine: ____ None ____ Minimal ____ Moderate ____ Heavy
Drug Use: ____ Marijuana ____ Cocaine
____ Crack ____ Heroin
____ Other (please list): ______________________
Occupation: __________________________________________________________________________
If you are unemployed, how long? ___________________________________________
What is the reason?
____ Physically unable to work
____ Emotionally unable to work
____ Lack of available jobs in the field
____ Lack of skills
____ Appearance inappropriate for position sought

Are you currently disabled or on disability? _____ No _____ Yes

If so, how long? __________________

Education:
_______ 8th grade or less ______ High school graduate ______ College graduate
_______ Some high school ______ Some college
______ Post graduate work
REVIEW OF SYSTEMS
General
What is your daily functional status?
_____ Independent _____ Partially disabled _____ Totally disabled
Are you currently pregnant?
_____ No _____ Yes

Have you had any surgery in the past 20 days? _____ No _____ Yes
Please check yes or no for each question
Cardiac
Do you have irregular heart beats?
_____ No _____ Yes
Do you have a heart valve abnormality?
_____ No _____ Yes
Have you had rheumatic fever?
_____ No _____ Yes
Do you have a pacemaker?
_____ No _____ Yes
Have you ever had congestive heart failure?
_____ No _____ Yes
Do you have pulmonary hypertension? _____ No _____ Yes
Have you ever had a heart attack (MI)?
_____ No _____ Yes
Have you had previous heart surgery?
_____ No _____ Yes
Have you had an angioplasty or stent placement? _____ No _____ Yes
Have you had any chest pain or angina in the past 30 days?
_____ No _____ Yes
Have you had any swelling in your legs? _____ No _____ Yes
Results of previous testing:
Have you ever had an EKG?
_____ No _____ Yes
If yes, what were the results?
_____ Normal _____ Abnormal
_____ Further testing required
Have you ever had a stress test?
_____ No _____ Yes
If yes, what were the results?
_____ Normal _____ Abnormal
_____ Further testing required
Have you ever had an echocardiogram?
_____ No _____ Yes
If yes, what were the results? _____ Normal _____ Abnormal
_____ Further testing required

Have you ever had cardiac catheterization? _____ No _____ Yes
If yes, what were the results? _____ Normal _____ Abnormal
_____ Further testing required
Pulmonary
Do you have any history of severe emphysema?
_____ No _____ Yes
Do you have any history of severe bronchitis?
_____ No _____ Yes
Do you have any history of severe COPD?
_____ No _____ Yes
Do you have asthma?
Are you being treated for pneumonia or bronchitis now?
_____ No _____ Yes
Have you had any wheezing recently?
_____ No _____ Yes
Do you have shortness of breath at rest?
_____ No _____ Yes
Do you have shortness of breath on exertion?
_____ No _____ Yes
Do you have a history of pulmonary embolism?
_____ No _____ Yes

Gastrointestinal
Do you have any liver disease?
_____ No _____ Yes
Have you had any yellow color to your eyes/skin?
_____ No _____ Yes
Have you had trouble with your gallbladder?
_____ No _____ Yes
Have you had any changes in bowel movements?
_____ No _____ Yes
Have you had any abdominal pain recently?
_____ No _____ Yes
Have you had any rectal bleeding recently?
_____ No _____ Yes

Vascular
Have you had a previous amputation?
_____ No _____ Yes
Have you had bypass surgery in a leg?
_____ No _____ Yes
Do you have pain in your legs at rest?
_____ No _____ Yes
Are you on dialysis for renal failure?
_____ No _____ Yes
Have you ever had a deep venous thrombosis (DVT)?
_____ No _____ Yes

Musculoskeletal
Do you have any bone or joint problems?
_____ No _____ Yes
Do you have any muscle weakness?
_____ No _____ Yes
Do you have any muscle pain?
_____ No _____ Yes
Do you have arthritis?
_____ No _____ Yes
Do you have chronic back problems?
_____ No _____ Yes
Do you have fibromyalgia?
_____ No _____ Yes
Do you have swollen ankles?
_____ No _____ Yes
Do you have varicose veins?
_____ No _____ Yes

Central Nervous System
Do you have any paralysis or partial paralysis of legs/arms? _____ No _____ Yes
Do you have a history of TIA’s or mini-strokes?
_____ No _____ Yes
Do you have any history of CVA (stroke)?
_____ No _____ Yes
Do you have any history of dizziness?
_____ No _____ Yes
Do you have any history of loss of consciousness? _____ No _____ Yes
Do you have any history of seizures? _____ No _____ Yes

Skin
Do you have rashes? _____ No _____ Yes
Do you have psoriasis? _____ No _____ Yes
Do you have non-healing lesions? _____ No _____ Yes
Do you have any history of melanoma? _____ No _____ Yes
Do you have any history of other skin cancers? _____ No _____ Yes
Emotional
Do you have anxiety? _____ No _____ Yes
Do you have depression? _____ No _____ Yes
Are you undergoing psychiatric therapy? _____ No _____ Yes
Endocrine
Do you have any history of thyroid disorder? _____ No _____ Yes
Do you have any history of heat or cold intolerance? _____ No _____ Yes
Are you taking thyroid medication? _____ No _____ Yes
Do you have any history of diabetes? _____ No _____ Yes
Are you on oral medication or insulin for diabetes? _____ No _____ Yes
Do you have excessive thirst, hunger, or urination? _____ No _____ Yes
Do you have any history of an adrenal disorder? _____ No _____ Yes
Do you have any history of a pituitary disorder? _____ No _____ Yes
Hematologic/Lymphatic
Do you have any history of anemia?
_____ No _____ Yes
Do you bruise easily?
_____ No _____ Yes
Do you have any history of excessive bleeding? _____ No _____ Yes
Have you had a blood transfusion in the last six months? _____ No _____ Yes
Do you have any history of swollen glands? _____ No _____ Yes
Do you have any history of leukemia or lymphoma?
_____ No _____ Yes
Do you have sickle cell? _____ No _____ Yes
Are you on medication for anti-coagulation? _____ No _____ Yes
Infectious
Are you HIV positive?
_____ No _____ Yes
Do you have any history of hepatitis?
_____ No _____ Yes
If yes, what type? _____ A _____ B _____ C
Do you have any history of staph infection?
_____ No _____ Yes
Do you have any history of MRSA or ORSA?
_____ No _____ Yes

Breasts
Do you have a current breast mass?
_____ No _____ Yes
Do you have any nipple discharge?
_____ No _____ Yes
Do you have a personal history of breast cancer?
_____ No _____ Yes
Do you have a current abnormal mammogram or sonogram? _____ No _____ Yes
When was your last mammogram? ______________________
Are you overdue for mammogram?
_____ No _____ Yes
Have you had breast augmentation?
_____ No _____ Yes
Miscellaneous
Do you wear glasses?
_____ No _____ Yes
Do you wear contacts?
_____ No _____ Yes
Do you have regular dental check-ups?
_____ No _____ Yes
Have you previously had dental surgery?
_____ No _____ Yes
Do you wear dentures?
_____ No _____ Yes
If yes, please check: _____ Upper _____ Lower
Do you have missing teeth?
_____ No _____ Yes
If yes, how many ? ________
Do you have any open wounds?
_____ No _____ Yes
Are you on any steroid medicine?
_____ No _____ Yes
Have you lost weight in the past six months?
_____ No _____ Yes
Have you had any chemotherapy in the past 30 days?
_____ No _____ Yes
Have you had any radiation in the past 90 days?
_____ No _____ Yes

Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations? This survey refers to your
usual way of life today. Even if you have not done some of these things recently, try to imagine how
you would have been affected. Use the following scale to choose the most appropriate number for each
situation:

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g. movie theater)
As a passenger in a car for an hour with no break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch with alcohol
Sitting quietly after lunch with no alcohol
In a car, while stopped for a few minutes in traffic
I attended the Baptist Center for Bariatrics informational seminar on _____/_____/_____
____________________________________ _____/_____/_____
Patient’s signature Date
You may wish for North Florida Surgeons and Baptist Health to discuss your confidential information
with others (such as spouse, partner, family member, etc.). We need your permission to do this.
_______ I DO NOT authorize North Florida Surgeons and Baptist Health to discuss my confidential
information.

_______ I DO authorize North Florida Surgeons and Baptist Health to discuss my confidential

information with:

Name: _______________________________________________ Relationship: __________________
Name: _______________________________________________ Relationship: __________________
Name: _______________________________________________ Relationship: __________________
____________________________________ _____/_____/_____
Patient’s signature Date

PLEASE COMPLETE THIS FORM AND EITHER BRING IT TO YOUR STEP 2 OFFICE VISIT OR
RETURN IT PRIOR TO YOUR VISIT BY FAX:
904.391.5451, ATTN: Bariatrics Coordinator Questions? Call 904.202.7546

Source: http://www.baptistbariatrics.com/docs/Baptist%20Center%20for%20Bariatrics%20Intake%20Form.pdf