Microsoft word - bariatric new patient.doc

PATIENT INFORMATION FORM
MR / MRS / MISS / MS / DR SURNAME:____________________________ FIRST NAME/S: ________________________
DATE OF BIRTH: _______/_______/_______
MALE / FEMALE

ADDRESS: ___________________________________________________________________________________
_________________________________________________________________________________________
HOME PH: ____________________ WORK PH: ______________________ MOBILE: _________________________
EMAIL ADDRESS: ______________________________________________________________________________
GENERAL PRACTITIONER: ________________________________________________________________________
MEDICARE NUMBER: ___________________________ REF. NO (BESIDE YOUR NAME):_____ EXPIRY DATE: ______/______
PRIVATE HEALTH INSURANCE?
VETERAN AFFAIRS NUMBER (IF APPLICABLE): __________________

IF YES, FUND NAME: _________________________________ FUND NUMBER: __________________________
COMMONWEALTH CONCESSION CARD? YES / NO CARD NO. ___________________ EXPIRY DATE: ______/______
NEXT OF KIN: ________________________________________________________________________________
RELATIONSHIP: ____________________________
CONTACT NUMBER: _________________________________

ARE YOU DIABETIC? YES / NO DO YOU HAVE: HEP B? YES / NO HEP C? YES / NO HIV? YES / NO

In December 2000 an amendment act was passed through the Federal parliament relating to the Privacy Act. This amendment came into effect on 21/12/2001. We require your consent to collect personal information about you. Please read this form carefully, and sign where indicated below. Queensland Bariatrics, the Wesley Obesity Clinic, Dr Blair Bowden and Dr Jennifer Duncombe collect information from you for the primary purpose of providing quality health care. We ask that you provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways: o Administrative purposes in running our medical practice. Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals. Emergency situations whereby medical officers/hospitals require access to patient notes for treatment purposes. Disclosure for research and quality assurance activities to improve individual and community health care and practice management.
I have read the information above and understand the reasons why my information must be collected. I am also aware that Queensland Bariatrics, the
Wesley Obesity Clinic, Dr Blair Bowden and Dr Jennifer Duncombe have a privacy policy on handling patient information.
I understand that I am not obliged to provide any information requested of me, but my failure to do so might compromise the quality of the health
care and treatment of me.
I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I
understand I will be given an explanation in these circumstances.
I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I
notify this practice of.
I consent to be contacted by email, telephone or SMS to confirm upcoming appointments or to send me patient related information.
PATIENTS NAME: ______________________________________
DOB: __________________________

SIGNATURE: _________________________________________
DATE: __________________________
QUEENSLAND BARIATRICS
NEW PATIENT SURVEY
PATIENT NAME: ______________________________________________________


HOW DID YOU HEAR ABOUT OUR CLINIC?
OTHER: ___________________________________________________________

HAVE YOU PREVIOUSLY ATTENDED A LAPAROSCOPIC GASTRIC BANDING INFORMATION SEMINAR?


IF NO, WOULD YOU BE INTERESTED IN ATTENDING AN INFORMATION SEMINAR?

WHAT ARE YOUR REASONS BEHIND CONSIDERING GOING AHEAD WITH SURGERY?
E.G. HEALTH, QUALITY OF LIFE, CLOTHING NOT FITTING, SOCIETY, JOB
_____________________________________________________________________________________________ THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.
SOCIAL PROFILE
Children and their ages: _________________________________________________________________________________ Do you have support persons/friends: ______________________________________________ Fulltime / Part Time / Casual /Unemployed If unemployed, what is the reason? _______________________________________________________________________ If unemployed, are you currently looking for work? Has your weight made it difficult to find work? If employed, what level of activity does your job involve? Little (Sedentary) Moderately Active Very Active WEIGHT HISTORY
Details of any other weight loss measures (including surgical): ________________________________________________ ______________________________________________________________________________________________________ Was there any particular event which lead to significant weight gain, if so what? ________________________________ ______________________________________________________________________________________________________ PERSONAL MEDICAL HISTORY
Please give details of any major illnesses or problems: _______________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ FAMILY MEDICAL HISTORY
SOCIAL HISTORY
_________________________________________________________________________________________ Alcohol Intake (standard drinks per week): _________________________________________________________________ Cigarettes: If yes, how many per day? _______ For how long? _______years. Ceased? _______ FOR THE LADIES ONLY
Do you have regular periods (26-33 days)? If not, please give details: _______________________________________________________________________________ Do you have problems with excessively heavy periods? If yes, please give details: _______________________________________________________________________________ Have you had difficulty conceiving in the past? Do you currently have problems with infertility? Have you suffered from excess body hair or acne? Have you been told that you have polycystic ovaries? Have you had problems child birth or pregnancy? If so, in what way? ______________________________________________________________________________________ Have you had a caesarean section? If so, please give details: ________________________________________________________________________________ SURGICAL HISTORY
Please give details of any past operations: __________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ MEDICATIONS
Please list all medications used in the past twelve months ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ SLEEP HISTORY
How many hours sleep do you get a night? ______hrs How would you consider your quality of sleep? ____________ Is there anything that keeps you awake at night? Details: _______________________________________________________________________________________________ If your sleep is a major problem to you or your partner, would you be prepared to have a sleep study? Yes / No During the last month, have you had, or have you been told about the following symptoms:
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?
In the car, stopped for few mins in traffic BREATHING HISTORY
Does being at work ever make your chest tight or wheezy? Details: _______________________________________________________________________________________________ Have you ever had to change jobs as it was affecting your breathing? Details: _______________________________________________________________________________________________ Have you ever worked in a job, which exposed you to vapours, gas, dust or fumes? Details: _______________________________________________________________________________________________ Have you ever had an asthma attack? Never Currently In the Past Don’t Know Have you ever been admitted to a hospital due to asthma or breathing problems? In the last 12 months, have you visited an emergency room or a doctor urgently due to asthma or breathing problems? Yes Details: ___________________________________________________________________________ Do you get short of breath on exertion? Yes / No Do you bring up phlegm when coughing? Yes / No Do you get short of breath walking up hills? Yes / No In the past 12 months……. Have you had an attack of shortness of breath that came on with no obvious cause? Have you had wheezing on your chest that came on after you stopped exercise? Have you had a feeling of chest tightness when waking in the morning? What exercise do you do on a regular basis and how often? (e.g. team sports, walking, swimming, gym) ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ GASTRO-OESOPHAGEAL REFLUX / INDIGESTION HISTORY
Do you have a history of heartburn or indigestion? Yes / No Details: __________________________________ If yes, how often do you have reflux during the day? Many Times Everyday Most Days Most Weeks Occasionally Do you suffer from heartburn/indigestion during the night? If so, how often? Many Times Every Night Most Nights Most Weeks Occasionally Details: ________________________________________ Details: ________________________________________ Does food or fluid reflux in your mouth? Yes / No Details: ________________________________________ Details: ________________________________________ Details: ________________________________________ Details: ________________________________________ Details: ________________________________________ Please list any treatments you use for heartburn, reflux or indigestion: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ANY OTHER RELEVANT INFORMATION?
______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ THIS SECTION WILL BE COMPLETED BY THE NURSE DURING YOUR CONSULTATION
MEDICAL ASSESSMENT
Other: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Source: http://www.lapbandbrisbane.com.au/wp-content/uploads/forms/Bariatric-New-Patient.pdf