Patient Information

Please fill out this registration form, paying attention to each section. This information will be used to create your patient record and to conduct a better assessment of your pre-operative health condition, which will help determine if you are a suitable candidate.

Patient Informaton

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Full Name *

Age *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Surgery Request

Date of Birth *

Gender *

Phone Number *

Marital Status

Date of Surgery

Time

Medical History

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Have you had any previous surgery?

Current Health Conditions *

Allergies *

Previous Medications *

If yes, please list de surgeries

Past Medical Conditions *

Current Medication *

Family Medical History *

Have you ever had any of the following:

If you have answered yes to any of the above questions, please list the details below if appropriate:

Medications currently taken

Please list doses and the interval taken, name of medication, dose and number of times taken per day:

Family History

Please complete the following information regarding your close relatives: if deceased, please enter age at death and cause of death:

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Father

Mother

Please enter any other important family history not listed above:

Social/ Personal History

Please indicate if any blood relative had any of the following conditions:

Drugs recently taken - within the past six months

Mark all the appropiate

NSAID's (such as ibuprofen, naprosen. eg. Advil, Aleve, etc)
Anticoagulants (such as Coumadin or Warfarin) Tranquilizers
Acetominophen (such as Tylenol)
Alternative or Complementary meds
Diet aids, supplements or prescriptions
NSAID's (such as Vioxx and Celebrex, etc) Cortisone / Steroids / ACTH
Hypotensives (high blood pressure medicines) Aspirin Antibiotics
Herbals Supplements

Allergies and sensitivities

Other drugs or medication

System Review

General

Gastrointestinal

Skin

Respiratory

Gynecological

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Gynecological

Periods

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Age started/ Year

Pregnancies

Age Duration

Miscarriages

Frequency

Date of first day of last period

Neck

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Stiffness

Thyroid trouble

Head Eyes Ears Nose Throat

Cardiovascular

Genitourinary

Locomotor- mulculoskeletal

Neuro- Psychiatric

Hematologic

Psychological Evaluation

Have you ever been in any kind of counseling or therapy? Please describe:

Are you or have you ever been under a psychiatrist's care? If yes, what was your diagnosis?

Have you ever participated in a support group? Please describe:

Are you or have you ever taken psychiatric medications? Please describe and for what purpose:

How long has excess weight been an issue in your life?

What methods have you tried to lose weight?

What do you hope to obtain from this surgery?

What are some of the changes you want to make in your lifestyle upon having this surgery?

Emergency Contact

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Emergency Contact Name *

Phone Number *

Relationship *

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