Please list all prior surgeries: I agree to a blood transfusion in an emergency situation Tape Allergies? Yes No Latex Allergies? Yes No Do take any NSAIDS such as Ibuprofen, Motrin, Aleve, Celebrex or Naprosyn? Yes No Do you currently have an abdominal / incisional hernia? Yes No Do you take any blood thinning medications such as Coumadin, warfarin, aspirin, or Plavix? Yes No I use tobacco(including smoke, dip, chew, nicotine gum/patches): How Often: How Many Years: When Did You Quit: I drink alcohol: How Often: How Many Years: When Did You Quit: I use recreational Drugs: How Often: How Many Years: When Did You Quit: I use Birth Control: Pills Condoms Tubal Ligation Other: Do you have or use any of the following: HYPERTENSION (HIGH BLOOD PRESSURE) DIABETES MELLITUS SLEEP APNEA - CPAP or BI PAP HEART DISEASE LUNG DISEASE (COPD/Emphysema) - Home Oxygen PULMONARY EMBOLISM SHORTNESS BREATH AND EXERCISE INTOLERANCE DUE TO OBESITY ASTHMA BLOOD CLOTS BLOOD TRANSFUSION LIVER DISEASE ( Hepatitis B, Hepatitis C ) HIV/ AIDS KIDNEY DISEASE - Dialysis THYROID PROBLEMS LUPUS HEARTBURN/REFLUX INDIGESTION / DYSPEPSIA PROBLEMS SWALLOWING / EXCESSIVE CLEARING OF THROAT ACID METALLIC IN MOUTH / SOUR STOMACH COUGHING / HOARSENESS VOMITING OR REGURGITATION WHEN DOWN FOOD GETS STUCK IN THROAT GASSINESS / BLOATING STOMACH COLITIS DISEASE/ ULCERATIVE COLITIS HYPERCHOLESTEROLEMIA (ELEVATED CHOLESTEROL) HYPERTRIGLYCERIDEMIA (ELEVATED TRIGLYCERIDES) URINARY STRESS INCONTINENCE (WEAK BLADDER) CHRONIC BACK AND JOINT PAIN ARTHRITIS MIGRAINE HEADACHES EDEMA (LEG SWELLING) DEPRESSION / BIPOLAR DISORDER/ANXIETY FREQUENT PREDNISONE USE FAMILY HISTORY: OBESITY, DIABETES, HYPERTENSION, HEART DISEASE, CANCER Last name: D.O.B.: Medication Allergies? Yes No If Yes, please list:
Supervised Weight Loss Attempts – Please check all of the weight loss efforts you have tried Home Gym Equipment Gym Membership Health Spa Calorie Counting High Protein Low Carb Low Fat Hypnosis Atkins Diet Mayo Clinic Diet Richard Simons Scarsdale Diet Sugar Busters Slim Fast Beach Diet Acupuncture Diet Pills from MD Diet Shots from MD Diet Center Craig Overeaters Anonymous Optifast / Medifast LA Weight Loss Nutri System Psychological Counseling Supervised Calorie Counting T.O.P.S. Weight Watchers Harris Fast Check Each Medication you have tried: Acutrim OTC Adipex Amphetamines Dexatrim OTC Fastin Herbal Remedies OTC Ionamin Meridia Metabolife OTC Phentermine Pondimin Phen fen Duration: Redux Tenuate Trimspa OTC Xenical Zenadrine OTC Level of Activity: Activity: Aerobics-Land Duration: Frequency: Limitations: Shortness of breath/pain Aerobics-Water Biking Organized Exercise Stairs Swimming Walking Do you use any of these walking aids daily? Cane Walker Wheelchair Motorized Cart / Last name: First: D.O.B.: Please use the scale below to describe to what degree the problems listed below have BOTHERED or DISTRESSED you during the past week, including today. Nervousness or shakiness inside Unwanted thoughts, words, or ideas that won’t leave your mind The idea that someone else can control your thoughts Feeling others are to for most of your troubles Trouble remembering things Feeling easily annoyed or irritated Feeling afraid in open spaces or in the street Thought of ending your life Hearing voices that other people do not hear Feeling that most people cannot be trusted Crying easily