The following information is very important to your health. Please take time to fully and completely fill out this important
information. We are counting on you.

If the insurance coverage is through the spouse or
ALTERNATE PHONE: _________________________ parent the following information is required:
DOB: ______________________________________ EMPLOYER ____________________________________ BUSINESS PHONE ______________________________ INSURANCE CO. ________________________________ POLICY ID# ________________________________ GROUP # __________________________________ DRIVER’S LICENSE#: _________________________ BUSINESS ADDRESS: _________________________ PHYSICIAN’S PHONE: ___________________ INSURANCE COMPANY_________________________ ____________________________________________ EMERGENCY CONTACT (relative, friend, or neighbor)
I hereby authorize payment of benefits directly to the attending physician. I hereby authorize the physician to release any information acquired in the
course of my examination and treatment to permit processing of claims for insurance reimbursement. A photocopy of this signature is valid as the
original. We will be happy to assist you with your insurance billing. Although an insurance claim is filed, the patient is responsible for the
account with us.

Signature of Patient or Representative: _________________________________

Please have insurance cards available for copying. We will be happy to assist you with your insurance billing. Although an insurance claim
is filed, the patient is responsible for the account with us.

COMORBIDITIES (circle if you have any of the following):
Abdominal Hernia / Abdominal Skin Pannus (problems with the abdominal skin irritation because of excess skin) Alcohol Use / Angina or Chest Pain / Asthma / Back Pain / Cholelithiasis (gallbladder diasease) / Mental Health Problems (like anxiety, bipolar, psychosis) / Congestive Heart Failure / Depression / Deep Venous Thrombosis or Pulmonary Embolism / Fibromyalgia / Functional Status (bedridden, wheelchair, cane, crutches) / GERD (heartburn, reflux disease) / Glucose Metabolism (glucose intolerance, diabetes) / Gout / Hyperuricemia (increased uric acid) / Hypertension / Ischemic Heart Disease (Heart Attack, myocardial infarction) / Hyperlipidemia / Liver Disease (fatty liver) / Lower extremity edema or swelling / Menstrual Irregularities / Musculoskeletal Disease (Foot,Ankle,Knee Pains) / Obesity Hypoventilation Syndrome / Sleep Apnea / Peripheral Vascular Disease (stroke, leg pain when walking) / Polycystic Ovarian Syndrome / Pseudotumor Cerebri / Psychosocial Impairment / Pulmonary Hypertension / Urinary Incontinence (Leakage of Urine With Coughing, Sneezing, or Laughing) / Substance Abuse (of illegal or PROBLEM LIST
Please circle all symptoms you currently experience, or have experienced in the past few weeks. Feel free to add any additional problems or information.
1. HEAD, EYE, EAR, NOSE & THROAT: stuffy Nose – runny Nose – hay fever – sinus trouble – earache – headache – blurry
vision – double vision – haloes around lights – loss of night vision – buzzing in ears – ringing in ears – discharge from ear – loss of hearing – dizziness – vertigo – loss of balance – sore throat – lump in throat – trouble swallowing – pain with swallowing – 2. RESPIRATORY: cough – wheezing – shortness of breath at night – use of two pillows – blood in sputum – out of breath with
exertion – wake up at night short of breath – wake up at night coughing or choking – asthma – emphysema – bronchitis 3. CARDIOVASCULAR: palpitations – pounding heart – skipping heartbeat – pains in chest – pains in neck – pains in arms –
squeezing of chest – heart attack – heart murmur – abnormal electrocardiogram – irregular heartbeat – high blood pressure – pain in legs – cold feet – blue toes – blue finger – loss of pulse 4. GASTROINTESTINAL: heartburn – nausea – vomiting – belching fluid in throat – burning in throat – food sticking in chest –
pains in stomach – burning in stomach – acid stomach – diarrhea – constipation – pain with bowel movement – blood in stools – hemorrhoids – fissures – cramps – gassiness – irritable colon – colitis
5. GENITOURINARY: pain with urination – trouble starting urine – trouble stopping urine – small urine stream – blood in urine –
kidney stones – bladder stones – kidney failure – nephritis – urinary tract infection – frequent urination – getting up at night to urinate – leakage of urine with cough or sneeze Men: discharge from penis – loss of erection – painful erection Women: vaginal discharge – vaginal bleeding – pain with intercourse – irregular periods 6. ENOCRINE (GLANDULAR): low thyroid – hyperthyroid – goiter – Grave’s Disease – thyroid Nodules – xray to thyroids –
diabetes – adrenal gland tumor – frequent flushing – frequent heavy sweating 7. MUSCULOSKELETAL: pain in joints- selling of joints – redness of skin over joints – warm joints – fluid in joints – arthritis –
broken bones – sprains – low back pain – hip pain – knee pain – ankle pain – foot pain – flat feet – slipped disk – herniated disk – 8. NEUROLOGICAL: dizziness – vertigo – falling to the side – falling at night – numbness – tingling – pins and needles feeling –
weakness of any muscles – twitching of muscles – weakness of grip – shakiness – tremors – fainting – convulsions – fits – loss of 9. PHYCHOLOGICAL: nervousness – anxiety – depression – thoughts of suicide – suicide attempts – hospitalization for
emotional problems – psychiatric treatment – psychological counseling MEDICATIONS (list all current medications that you are taking)
**** if more, put other medicines on back of form*** FAMILY HISTORY:
______________________________________________ The above is true and correct to the best of my belief.
Note: At the time of your visit it is very helpful to review recent medical evaluations and any laboratory studies which you may have had recently performed. Please bring copies with you or request that they be mailed or faxed prior to the date scheduled for

Source: http://uhealthbariatrics.com/documents/50_005_Patient_Information_Form.pdf

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