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Online Bariatric Surgery Questionnaire

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Online Bariatric Surgery Questionnaire

Contact Information

Full Legal Name This field is required.

Address This field is required.

City This field is required.

State This field is required.

Zip This field is required.

Daytime Phone This field is required.

xxx-xxx-xxxx

Email This field is required.

Insurance Information

Insurance Company Name This field is required.

Policy or Member Number This field is required.

Insurance customer service phone number

Policy Holder's Name This field is required.

Policy Holder's Date of Birth This field is required.

Do you have secondary insurance coverage?

Yes

Secondary Insurance Company Name

Secondary Policy or Member Number

Secondary Policy Holder's Name

Secondary Policy Holder's Date of Birth

Secondary Insurance Customer Service Phone Number

About the Patient

Sex This field is required.

Male

Female

Date of Birth This field is required.

Height This field is required.

ex. 5' 8"

Current Weight This field is required.

Are you currently non-mobile (wheelchair or bed bound)? This field is required.

Yes

Medical History

Diabetes

Heart Disease

High Blood Pressure

Sleep Apnea

Diagnosed by sleep study?

Daytime Sleepiness

Snoring

Reflux (Heartburn)

High Cholesterol

High Triglycerides

Joint Pain

Back Pain

Hip Pain

Knee Pain

Ankle and Foot Pain

Swelling of Feet

Urinary Stress Incontinence

Blood Clots

Deep Vein Thrombosis (DVT)

Pulmonary Embolism

Stroke

Shortness of Breath

Asthma

Emphysema

Headaches

Migraines

Kidney Disease

Seizures

Rashes

Arthritis/Osteoarthritis

In a weight bearing joint?

Cancer

Irregular Periods

Eating Disorder

Eating Disorder Explanation

Non-Alcoholic Fatty Liver or Non-Alcoholic Steatohepatitis

Other (please specify)

Other Medical Issues

Have you had a serious illness? This field is required.

Yes

Please describe any serious illnesses

Indicate the year of the event and your age at the time

Have you ever been hospitalized? This field is required.

Yes

Why were you hospitalized?

Indicate the year of the event and your age at the time

Have you ever had surgery? This field is required.

Yes

Indicate the year, type of surgery, and whether it was laparoscopic

Do you have allergies to any medications? This field is required.

Yes

Please describe your allergies

Mental Health History

In the past 2 years have you undergone any counseling or psychiatric treatment? This field is required.

Yes

Have you ever been diagnosed with any of the following conditions?

Depression

Severe Depression

Bipolar Disorder

Anorexia

Bulimia

Schizophrenia

I do not have any of these conditions

Check all that apply

Have you ever been hospitalized for a mental health issue? This field is required.

Yes

Please indicate the most recent date and reason

Medications

Do you routinely take medications? This field is required.

Yes

Prescription or over the counter

Please list current medications and dosages

Chemical Use

Do you use tobacco or nicotine products? (chew, cigarettes, cigars, e-cig, pipes, etc.) This field is required.

How much do you currently use?

When did you quit?

Do you have a history of either alcohol, drug/substance abuse? This field is required.

Yes

Do you currently use?

Yes

Please describe the substance and frequency of use

Please describe the substance and when you quit

Surgical History

Have you previously had bariatric surgery? This field is required.

Yes

Please explain where, when, the type of procedure, and reason for seeking a revision

Please provide original bariatric surgery op report and recent testing

Dietary History

Which meals do you eat each day?

Breakfast

Lunch

Dinner

Do you currently follow a special diet? This field is required.

Yes

Please describe your current diet

Have you previously dieted? This field is required.

Yes

Please describe your most recent diet

During the last 3 months, did you have any episodes of excessive overeating? This field is required.

Yes

(ie. eating significantly more than what most people would eat in a similar time period.)

Do you ever feel distressed about your episodes of excessive overeating?

Yes

During your episodes of excessive overeating, how often did you feel like you had no control over your eating?

Never or Rarely

Sometimes

Often

Always

During your episodes of excessive overeating, how often did you continue eating even though you were not hungry?

Never or Rarely

Sometimes

Often

Always

During your episodes of excessive overeating, how often were you embarrased by how much you ate?

Never or Rarely

Sometimes

Often

Always

During the last three months, how often did you make yourself vomit as a means to control your weight or shape?

Never or Rarely

Sometimes

Often

Always

Other Information

Have you ever been a patient at UI Hospitals & Clinics? This field is required.

Yes

Preferred contact method

At the University of Iowa we treat all health information as personal and confidential. Health information will only be given to a patient in person or via direct phone contact unless the patient gives express permission to provide Protected Health Information in another way. Please indicate your preference for receiving health information to the following questions.

I may be contacted on my cell phone

A message can be left on my cell phone voice mail

Protected Health Information can be left on my voice mail at home

Protected Health Information may be sent to me via my home email

I can be contacted at my work phone number

Protected Health Information may be left on my voicemail at work

Protected Health Information may be sent to my work emailI would like a copy of my Protected Health Information sent to my Family Physician

I would like a copy of my Protected Health Information sent to my Family Physician

Attestation

I understand the importance of providing accurate information and have completed this form to the best of my ability. This field is required.

Leave this field blank

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Surgery

Locations and Offices

James A. Clifton Digestive Health Center

4501 John W. Colloton Pavilion (JCP)

Level 4, Elevator F

1-319-356-4060

Clinic

In University of Iowa Hospitals & Clinics

200 Hawkins Drive, Iowa City, IA 52242

Clinical Trials currently in progress

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Patient Stories

Bariatric surgery helps Melissa look and feel her best

November 29, 2017

Melissa's surgery team for her bariatric surgery was led by UI bariatric surgeon Jessica Smith, MD. The Roux-en Y procedure was a success, and Melissa...

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September 5, 2017

“This whole operation was a way for me to completely take control of my life and become the person I really wanted to be” --Jared Cunningham from Ceda...

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