Patient Profile- Keith McEwen MD
Please complete as much as possible.
Email address *
Enter your First Name, Middle Initial, Last Name: *
Your answer
Date of birth? *
Your answer
Address including CITY STATE ZIPCODE *
Your answer
Best Telephone Number to contact *
Your answer
Secondary telephone #
Your answer
Approximate Height and Weight: *
Your answer
Enter your employer name: *
Your answer
Enter your primary care physician's name: *
Your answer
Insurance Carrier *
Your answer
Insurance Group Number *
Your answer
Insurance ID Number *
Your answer
If you are not the Subscriber, list Subscriber Name and Date of Birth:
Your answer
Insurance Pre-certification Telephone Number
Your answer
Insurance Member Service Telephone
Your answer
Do you have any allergies? *
If yes, list allergy and reaction
Your answer
LIST of your medications: *
Your answer
List any previous surgery or surgeries:
Your answer
Check YES or NO if you have the following: *
Yes
No
Alcohol Abuse
Anemia
Arthritis
Asthma
Auto-immune Disease or diseases
Bleeding or Clotting Disorder
Blood Clot (PE) Pulmonary Embolism
COPD
Cirrhosis of the Liver
Diabetes TYPE 1
Diabetes TYPE 2
GERD or REFLUX
Heart Disease
Hepatitis or Liver Disease
High Blood Pressure (HTN)
High Cholesterol or lipids
History of Cancer
History of Chronic Pancreatitis
History of a STROKE
History of problems or nausea with Anesthesia
Kidney or renal disease
Neurological disease
Urinary disease or disorder
Pain in BACK, FEET, KNEE, HIP or JOINT
Depression or history of depression
History of a mental disorder
History of a physical disability
History of illicit Drug Use
History of seizures or epilepsy
Sleep Apnea
TB (tuberculosis)
Do you use tobacco products currently?
If smoking cigarettes, are you willing to quit?
History of ULCERS (gastric or duodenal)
Portal Hypertension (RARE)
Gastroesophageal History (REFLUX) *
Yes
No
Do you have a history of heartburn or indigestion
Do you have reflux chonically
Do you have difficulty swallowing
Does food ever become "stuck"
Do you suffer from a regular nighttime cough
Have you had an EGD (scope) within last 2 years
FAMILY HISTORY *
Yes
No
Does NOT apply (adopted)
Is your mother obese
Is your father obese
Does either parent have diabetes
Does either parent have heart disease
FEMALES ONLY *
Yes
NO
Have you had a tubal ligation
Do you have regular periods
Do you have excessively heavy periods
Have you suffered from excess body hair or acne
Have you had a hysterectomy
Have you had fertility problems
Do you have polycystic ovarian disease PCOD
Weight Loss Attempts *
What is the most weight that you lost with the above methods: *
Your answer
How long has your weight been a problem *
Your answer
What is your personal weight loss goal *
Your answer
Do you have ANY food allergies or intolerances *
Have you had nutritional deficiencies in the past *
Your answer
Do you currently take any vitamins, minerals or herbal supplements *
Your current dietary intake: *
1 or less
2-4
More than 4
How many meals per day
How many snacks per day
How many beverages with calories per day
How many days per week do you exercise
How many times per week do you dine out
Do you have cravings or trigger foods- list *
Your answer
Patient Agreement to Participate- Behavior Contract
Bariatric surgery is major step towards improving your health and wellness. This agreement outlines the minimum requirements necessary to undergo bariatric surgery and be successful in your weight loss journey. Your surgery and overall success depends on your compliance with the following program requirements:
1. Your first day of consult is the first step in making a commitment to weight loss. You will work closely with our bariatric team. If you fail to lose weight prior to surgery, you will need further education and/or additional therapy before proceeding. Per our program requirements, industry standards, and many insurance policies, we reserve the right to postpone your surgery if weight gain occurs.
2. Required appointments, pre-op classes, and education will need to be completed. Pre-op nutrition and behavioral skills classes provide vital information including nutrition, exercise, and behavioral modifications. We offer these at NO COST for your convenience. It is a requirement for insurance and program approval. You must attend 2 REGULAR support groups prior to surgery in addition to SWL classes.
3. 24 hour notice to cancel appointments. No shows/no call or late cancellations can dismissed from the program.
4. Follow the nutrition and exercise guidelines prescribed. You are placed on a weight loss regimen. The ability to demonstrate appropriate weight loss efforts through compliance is necessary. A daily food and activity journal is required. We REQUIRE a 2% weight loss in addition to any BMI requirements. Our RD (Registered Dietitian) will provide.
5. Commit to understanding and completing any requirements from the clinical psychologist that are made. Recommendations are your responsibility to complete prior to scheduling surgery.
6. SMOKING/TOBACCO use is prohibited. Our program and many insurance policies, mandate that patients are tobacco free for at least SIX months prior to surgery. A nicotine test is required by many insurance carriers.
7. ALCOHOL USE is prohibited for 6 months before surgery on most governmental insurance plans. If you have a history of alcohol abuse, our program requires 12 months without use and treatment clearance.
8. ILLEGAL DRUGS or NON-PRESCRIBED DRUGS is prohibited for our program and most insurance plans. You are not a candidate for Bariatric Surgery if you are using recreational drugs, illegal drugs or NON-Prescribed Drugs.
9. The Lap Band System requires routine follow up care. Please acknowledge that you will be able to follow up monthly for the first 12 months then every quarter to six months depending on physician recommendations as long as you have a Lap Band System.
I understand that if I do not comply with the requirements above, I could jeopardize my health, weight loss success, or my suitability as a candidate for surgery. I understand that bariatric surgery is only a tool and does not guarantee my weight loss. After I receive bariatric surgery, I understand that these requirements continue as a lifetime commitment.
DO YOU UNDERSTAND THE AGREEMENT TO PARTICIPATE *
Please type your name & date as an agreement to all of the above information *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service