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Online Bariatric Surgery Questionnaire at the University Campus

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Online Bariatric Surgery Questionnaire at the University Campus

Contact Information

Full Legal Name [First, Middle, Last] This field is required.

Date of Birth This field is required.

Legal Sex This field is required.

Male

Female

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

Daytime Phone Type: Check All That Apply

Home

Cell

Work

Other

Is It OK to Leave a Voice Message?

Yes

If Cell, Is It OK to Send a Text Message?

Yes

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

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

Please explain

Medical History

Let us know if you currently have or previously had any of these medical conditions.

Diabetes Type I

Diabetes Type II

Hypertension/High blood pressure

Snore loudly

Feel Tired/ Fatigued/ Sleepy during the daytime

Been observed to stop breathing/choking/gasping during your sleep

Sleep Apnea

Diagnosed by sleep study?

GERD [reflux / heartburn]

Arthritis/Osteoarthritis

In a weight bearing joint?

Non-Alcoholic Fatty Liver or Non-Alcoholic Steatohepatitis

Eating Disorder

Eating Disorder Explanation

Heart Disease

High Cholesterol

High Triglycerides

Irregular Periods [PCOS]

Blood Clots

Deep Vein Thrombosis (DVT)

Pulmonary Embolism

Stroke

Emphysema

Kidney Disease

Seizures

Cancer

Have you had a serious illness other than what is listed above? This field is required.

Yes

Please describe any serious illnesses [List the type, year, your age, and if you were hospitalized for it.]

Medications

Do you routinely take prescription medications? This field is required.

Yes

Please list current medications and dosages

Do you routinely take over the counter medications/supplements? This field is required.

Yes

Please list current OTC medications/supplements and dosages

Do you routinely use birth control? This field is required.

Yes

N/A

Please list type of birth control

Surgical History

Have you ever had bariatric surgery [surgery for weight loss]? 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.

Have you ever had surgery for reason other than weight loss? This field is required.

Yes

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

Mental Health History

In the past 12 months have you undergone any counseling or psychiatric treatment? This field is required.

Yes

Have you ever been diagnosed with any of the following conditions? This field is required.

Depression

Severe Depression

Bipolar Disorder

Schizophrenia

Anorexia

Bulimia

Binge Eating Disorder

I do not have any of these conditions

Check all that apply

If any diagnosis is checked, please explain [dates/medication/treatment etc.]

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

Yes

If yes, please explain/provide most recent date of admission (month/year)

Tobacco / Nicotine / Vaping / Alcohol / Substance Abuse

Do you currently use any tobacco / nicotine / vaping products? This field is required.

Yes

Check all products you are currently using

Smokeless Tobacco (chew, dip, snuff, etc.)

Cigarettes

Vaping, any type (e-cig, vape, hookah, vape pen, mods, tanks, etc.)

Cigars

Pipes

Nicotine replacement products (gums, patches, lozenges, pouches, any type of vape)

How much of the selected products do you currently use?

Have you previously used any tobacco / nicotine / vaping products? This field is required.

Yes

Check all products you previously used, but have since quit

Smokeless Tobacco (chew, dip, snuff, etc.)

Cigarettes

Vaping, any type (e-cig, vape, hookah, vape pen, mods, tanks, etc.)

Cigars

Pipes

Nicotine replacement products (gums, patches, lozenges, pouches, any type of vape)

When did you quit smokeless tobacco? (month, year)

When did you quit cigarettes? (month, year)

When did you quit vaping? (month, year)

When did you quit cigars? (month, year)

When did you quit pipes? (month, year)

When did you quit nicotine replacement products? (month, year)

Do you have a history of alcohol or substance abuse? This field is required.

Yes

Please explain the substance type and date of last use [Month/Year].

Dietary History

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

Sometimes

Often

Always

Other Information

Have you ever been a patient at UI Health Care? This field is required.

Yes

Preferred contact method (outside of MyChart)

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

Sidebar content

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 Medical Center

200 Hawkins Drive, Iowa City, IA 52242

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...

Bariatric surgery, lifestyle changes shape Jared’s path to better health

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...

Browse more stories

Related News

Bariatric surgery recognized as Blue Distinction Center+

April 20, 2018

University of Iowa Hospitals & Clinics has received a Blue Distinction Center+ designation by Wellmark Blue Cross and Blue Shield for bariatric surger...

Bariatric surgery program achieves national accreditation

May 19, 2017

The University of Iowa Health Care bariatric surgery program has been accredited as a Comprehensive Center under the under the Metabolic and Bariatric...

Educational Resources

Life After Bariatric Surgery

Information About Bariatric Surgery

Tools for change with bariatric surgery

Post-bariatric surgery

Pre-operative bariatric surgery FAQs

Should I have bariatric surgery?

Patient's guide to bariatric surgery

What is sleeve gastrectomy?

What is gastric bypass surgery?

Dietary guidelines post bariatric surgery

The golden rules of bariatric nutrition and lifestyle guidelines

Exercise after bariatric surgery

Going back to work after bariatric surgery

Birth control and pregnancy after bariatric surgery

Long-term follow-up for bariatric surgery

Potential problems following bariatric surgery

How effective is bariatric surgery?

Risks of bariatric surgery

Am I a candidate for bariatric surgery?

General FAQs about bariatric surgery

Bariatric surgery diet-related FAQs

Support Groups

Bariatric Surgery Support Group

The Bariatric Surgery Support Group is a great way to share your experience and connect with others who have already started the journey.

Registration is not required; it is free and open to anyone interested in sharing their experience and/or considering bariatric surgery.

Bariatric Surgery Zoom Support Group meets from 6 to 7 pm:

January 13: Are you looking for a refresher on bariatric lifestyle changes? Erin Broege (Steinbach) MCN, RD, LDN, Bariatric Surgery dietitian will present "9 Daily Habits for Success" and Q & A. Join us!

Join Zoom Meeting
https://uiowa.zoom.us/j/93824479525?pwd=KKj4aRhPoeaOhfOPjSlXPJ4efR0IcE.1&from=addon

Meeting ID: 938 2447 9525
Passcode: 935697

More dates:
March 10
May 12
July 14
September 8
November 10

Online Bariatric Surgery Questionnaire at the University Campus

Patients and Visitors

Medical Professionals

Employees & Community