Lap Band Surgery

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The information in this form is an important part of planning your surgical care. Providing incomplete or inaccurate information could result in the delay or cancellation of your surgery as well as jeopardize the ability of the physician to provide the best possible care.

Patient Information


First Name		Last Name
Birth Date	MM / DD / YYYY
Age		Race
Address		City
State		Zip
Home Phone		Cell Phone
Email		Social Security #
Employer		Address
Occupation		Phone
City		State	Zip:

Emergency Contact Information


Name	Relationship
Phone	Address
City	State	Zip

Insurance Information


Insured Name			Insurance Renewal Date:
Address			City
State			Zip

Birth Date (mm/dd/yyyy)			Social Security No
Employer			Occupation
Address			City
State			Zip
Insurance Company			Group Number
Policy Number			Phone

Primary Care Physician Information


Physician Name	May we send your PCP information about your case?	Yes No
Address	Are you receiving disability benefits?	Yes No
Phone	Reason for Disability:
City
State
Zip


I authorize the release of necessary medical information to process my insurance claims. I authorize payment of insurance benefits for services rendered to:

Electronic Signature:		Date:
Parent Signature (if under 18):		Date:

Medical Information


Current Weight	lbs.	Are you a snacker?	Yes No
Current Height		Do you eat a lot of junk food?	Yes No
How long have you been overweight?		How often do you eat junk food?	/ weekly
Age you began first diet?	yrs.	Favorite foods:
Most weight you ever lost?	lbs.
How was weight loss obtained?
Surgery you are interested in
Are you currently under a physicians care for weight loss?		Yes No
If yes, name and address:

List any medical problems you have for which you have seen a doctor or been hospitalized.

List: Illness, Date, Treatment, and Outcome

Medical History


Diagnosed or treated for high blood pressure?		Chest pain when exercising?
Diagnosed or treated for diabetes?		Short of breath at rest?
High blood cholesterol?		Short of breath when exercising?
High blood fats or triglycerides?		Wake up at night short of breath?
Diagnosed with asthma?		Irregular or excessively strong heartbeats?
Diagnosed or treated for GERD?		Sleep lying flat?
Stomach ulcers?		Blackouts?
Blood clots in your leg veins?		Swollen ankles?
Have you ever been anemic?		Excessive bleeding from surgery or minor injuries?
Iron deficiency or taken iron?		Have you had easy bruising?
Diagnosed with hypothyroidism?		For Women:
Ever had thyroid surgery?		Heavy periods?
Thyroid replacement medication?		Still having periods?

Surgical History

List all surgeries and specify if done open or laparoscopically.

List: Surgery, Date and Reason


Have you had Weight loss surgery before?	Yes No
If Yes when and what type of surgery:
Does your religion prohibit you from receiving blood products?
Have you had your gallbladder removed?7
Have you had a hysterectomy?
Have you had a tubal ligation or had your "tubes tied"?

Medications

List all current medications, including prescriptions, vitamins, over-the-counter, and intermittently used drugs.

Include name, strength, frequency, purpose, and when you first started the medication.

List any allergies to medication and explain reactions you experienced.

Have you ever smoked tobacco products? If yes, how many years?

How many cigarettes per day?

Do you currently use tobacco products? If yes, how many per day?

Dietary History - Medically Supervised Diets

Diet Programs	Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.

Medi-Fast:
Opti-Fast:
Mayo Clinic:
Physician Diet Program:

Shots	Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.

B-6:
B-12:
Other:

Pills	Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.

Lasix (diuretic):
Xenical:
Meridia:
Other:

M.D./Clinic Name:

Dietary History - Non-Supervised Diets

Please fill out this section as accurately as possible. List all diets you have tried, how many times you have tried them, how long you were on the diet, and how much weight was lost and regained.

	Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.

Weight Watchers:
Nutri-System:
Jenny Craig:
Diet Center:
TOPS:
Overeaters Anonymous:

Liquid Diets	Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.

Slim Fast:
Sweet Success:
Liquid Protein:

Misc. Diets	Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.

Low Calorie Diet:
Low Fat Diet:
High Protein Diet:
Self-Imposed Fasting
Richard Simmons:
Herbal Life:
Cambridge Diet:
Atkins Diet:

OTC Diet Pills	Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.

Acutrim:
Dexatrim:
Metabolife:
Xenadrine:

Other Weight Loss Methods	Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.

Psychotherapy:
Acupuncture:
Hypnosis:
Subliminal Tapes:

Exercise	Include the number of times you tried the diet, how long you were on the diet, how much weight you lost and regained, and the approx. month and year you were on the diet.

Health Club:
Exercise Tapes:
Outdoor Activity:

I have provided complete and accurate information to the best of my knowledge.

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