2020 Patient Info- Keith McEwen MD
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Email address *
Enter your First Name, Middle Initial, Last Name: *
Date of birth: *
Address including CITY STATE ZIPCODE *
Best Telephone Number to contact *
Secondary telephone #
Approximate Height and Weight: *
Enter your primary care physician's name: *
Insurance Carrier *
Insurance Group Number *
Insurance ID Number *
If you are not the Subscriber, list Subscriber Name and Date of Birth:
Insurance Pre-certification Telephone Number
Insurance Member Service Telephone
EMPLOYERS NAME
Do you have any allergies? *
If yes, list allergy and reaction
LIST of your medications: *
List any previous surgery or surgeries:
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?
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"
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: *
How long have you been obese *
What is your personal weight loss goal *
Do you have ANY food allergies or intolerances *
Have you had nutritional deficiencies in the past *
Required
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 *
Patient Agreement to Participate- Behavior Contract

You are being considered or have been accepted for Bariatric surgery at the practice of Keith McEwen MD, Community Bariatric Surgeons Hamilton. To help determine whether this is the best option for you, an agreement about what is required of you both before and after the surgery is required. The success of the Bariatric procedure depends on you following a medical, behavioral, and nutritional program that includes clinic visits, an exercise program, dietary guidelines, and taking recommended vitamins and minerals every day for the rest of your life.

By signing below, I agree to make a commitment to myself and the Bariatric Team to take care of myself in the following ways:

1. Appointments and Education: I will follow the treatment plan as prescribed by my surgeon and Bariatric team, attend my clinic appointments, complete all mandatory labs, and take my medicine as directed. I will read the pre and post-surgery educational materials provided to me by the staff and ask questions about any content I do not understand. I will bring the materials to the hospital and/or clinic when requested.

2. Exercise: I will participate in the exercise plan as recommended by my surgeon and/or the Bariatric team. The Bariatric team may recommend a formal outpatient program or may recommend general exercise guidelines for home.

3. Dietary: I will follow the nutritional guidelines and restrictions as prescribed. I understand that I am placed on a weight loss regimen and must demonstrate continued appropriate weight loss through compliance with the recommended nutrition guidelines. I understand that these dietary changes, such as a healthy, well-balanced diet, will be crucial to my overall health after surgery. I will meet with the Bariatric dietitian as directed to review my diet record and nutritional needs. I will complete daily food records that will include all food and fluids consumed during the day. I will bring food records to appointments or forward them to the dietitian.

4. Alcohol and tobacco: If alcohol abuse or dependence has been identified as an issue for me, I commit to psychological intervention as deemed necessary. I must demonstrate 6 months of abstinence before being considered an appropriate candidate for Bariatric surgery. Tobacco cessation is required by most insurance carriers for 6 months prior to surgery.

5. Substance Abuse: I will not use any substances or drugs not prescribed by a physician. I will use prescription drugs as prescribed. I must demonstrate 6 months from undesirable/illicit drugs before being considered an appropriate candidate for Bariatric surgery. I commit to participating in any needed treatment programs to address substance abuse issues. I agree to sign a release of information document to allow the Bariatric team to monitor my progress and attendance in the chosen treatment program.

6. I commit to completing the requirements of the clinical psychologist pre surgically and/or post surgically. I commit to learning, resolving, and changing my specific situations, behaviors, weight loss barriers, emotions, or triggers and to seek immediate assistance if not in compliance. I understand that if I do not satisfactorily complete the clinical psychologist’s pre surgical requirements, I will jeopardize my suitability as a candidate for Bariatric surgery.

7. I commit to attending support groups as much as physically possible. I understand this is an important aspect of the program and an opportunity to receive ongoing education, support, and meet other Bariatric surgical patients.

8. I will contact the Bariatric team with any pre/postsurgical medical questions or changes in current health status. I will forward all required labs to the staff and follow given recommendations.

9. I understand that if I break this contract I could jeopardize my health, weight loss success, and/or suitability as a candidate for Bariatric surgery. I understand that in changing and/or maintaining healthy behaviors, relapses/lapses can occur. I commit to learning my specific situations, behaviors, or triggers for a relapse, pre and post surgically, and to seek immediate assistance to bring these under control. If I feel like I am going to break this contract, I will call a member of the Bariatric team for assistance. The Bariatric team agrees to provide names and teams of psychologists when necessary.

10. I understand that these requirements continue as a lifetime commitment. I take personal responsibility for my program success and will initiate follow-up as indicated with Bariatric team members. No promises or guarantees have been provided by my bariatric team.
DO YOU UNDERSTAND THE AGREEMENT TO PARTICIPATE *
Please type your name as an agreement to all of the above information *
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