Pre-Operative Patient Health Data

The Johns Hopkins Center for Bariatric Surgery General Information*

Patient Name Surgeon

v. 6.2 (2/10/2010)

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Visit Date

Dr. Lidor Dr. Magnuson Dr. Nguyen

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Dr. Schweitzer Dr. Steele

Patient's Street Address

Patient's City, State, Zip

Patient's Day Phone

Date of Birth (MM/DD/YYYY)

Age

Patient's Evening Phone

Patient's Email Address

Current Height

Current Weight

Primary Care Physician (PCP) * PCP Address, Phone, and Fax *

Referring Physician, if not your PCP, and Specialty (i.e., psychiatry, neurology, endocrinology)

Referring Physician Address, Phone, and Fax

Other Physician and Specialty (i.e., psychiatry, neurology, endocrinology)

Other Physician Address, Phone, and Fax

Insurance Provider *
Group and Policy Numbers

* - Required

Page 1 of 11

Patient Name: _________________________

History of Presenting Illness

Weight Loss Methods Attempted Supervised by Professional Sustained Over Six Months Attempted Within Last Two Years

c d e f g c d e f g c d e f g c d e f g c d e f g

None Exercise Program(s) Behavioral Modification Medication(s)

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c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

Phen Fen

Commercial Programs Weight Watchers Jenny Craig Optifast Nutrisystem Atkins

Self-created diet Other

Eating Habits - Check all that apply

c d e f g

Sweets

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Salty Snacks

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Night Eating

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Skipping Meals

Past Medical History

Past Conditions
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Alcohol/drug abuse Angina Apnea Arthritis Asthma Back pain Cancer Crohn's disease Deep vein thrombosis Depression Diabetes

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Diverticulosis Dyspnea on exertion (shortness of breath) Endometriosis Epilepsy/seizures Excessive bleeding after surgery or a cut Fatty liver Gallstones GERD Gout Heart attack Heart disease

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High blood pressure High cholesterol Irregular menses Irritable bowel syndrome Joint pain Kidney disease Kidney stones Leg swelling/ulcers Liver disease/hepatitis Lung disease Malnutrition

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Mental illness Plantar fascitis Polycystic ovarian syndrome Pseudotumor cerebri Stomach ulcer Stroke Thyroid disease Ulcerative colitis Urinary leakage

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c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

Other: _____________________________________________________________________________________

Page 2 of 11

Patient Name: _________________________

Past Surgical History Non-Bariatric Procedures

Procedure Year Procedure Year

c d e f g c d e f g c d e f g

Abdominal exploration Appendectomy Bowel resection

c d e f g

Hernia repair

c d e f g
c d e f g

Groin Abdominal Hiatal

c d e f g c d e f g c d e f g c d e f g
for:

Small bowel Colon

c d e f g
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Back operation/laminectomy Joint replacement

Cancer surgery

c d e f g
c d e f g

Hip(s) Knee(s)

Breast biopsy

c d e f g Benign c d e f g Cancerous c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g
Caesarian section Tubal ligation Hysterectomy Oophorectomy (Ovary removal) Mastectomy/operation for breast cancer Heart angioplasty and/or stent Heart catheterization Other heart procedure Colonoscopy Upper endoscopy

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Knee arthroscopy (exploratory surgery) Operation for reflux (GERD) Cholecystectomy (Gallbladder removal)

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Open Laparoscopic

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Other operations (please list below)

Bariatric Procedures*
Procedure Open or Laparoscopic? Year Original Weight Weight Lost

c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

Gastric Bypass (R-n-Y) Biliopancreatic Diversion (BPD) BPD with Duodenal Switch Adjustable Gastric Band Vertical Banded Gastroplasty Sleeve Gastrectomy Non-adjustable Gastric Band Intestinal Bypass Gastric Pacing Revisions to:

c d e f g c d e f g

______________________________ ______________________________

Page 3 of 11

Patient Name: _________________________

Medications*

Below, please list all medications that you have taken in the last 90 days, plus the dosage. Include over the counter medications, herbal supplements, and birth control medications.

Medication

Dosage

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c d e f g c d e f g

Plavix Coumadin Other blood thinner

c d e f g c d e f g

Multivitamin Vitamin B-12

c d e f g c d e f g c d e f g

Calcium Vitamin D Calcium with Vitamin D

c d e f g c d e f g

Iron Vitamin A, D, E Combo

Allergies
c d e f g
Medications

c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

Latex House dust mites Animal dander and saliva Tape Venoms from insect stings Other

c d e f g

Foods

c d e f g

Antibiotics type

c d e f g c d e f g c d e f g

Peanuts Seafood Other

reaction

c d e f g c d e f g c d e f g

Aspirin Narcotics Other

Page 4 of 11

Patient Name: _________________________

Social History Gender*

c d e f g c d e f g
Male
Female

Date of Birth (mm/dd/yyyy)

Race*
c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g
c d e f g
African American Asian Caucasian Hispanic Native American or Alaska Native Native Hawaiian or other Pacific Islander Other:

Marital Status
c d e f g c d e f g c d e f g
Single Married Domestic Partnership

c d e f g c d e f g c d e f g

Separated Divorced
Widowed

Occupation

Children
Date of Birth
(MM/DD/YYYY)

Gender M/F

Obese? Y/N

Employment Status*
c d e f g c d e f g c d e f g
Full Time Part Time Self Employed

#1.

Select
Select

Select

c d e f g c d e f g c d e f g c d e f g

Retired Disability Unemployed Not Specified

#2. #3. #4. #5. #6.

Select
Select

Select
Select Select

Select
Select

c d e f g Homemaker c d e f g Student

Select

Select

Please attach an additional sheet of paper if necessary.

Who Will Support Your During and After Your Surgical Weight Loss Process?

Tobacco Use*
j k l m n
None

Substance Abuse*
j k l m n j k l m n j k l m n
None Rare Occasional

Alcohol Use*
j k l m n j k l m n j k l m n c d e f g
None Rare

j k l m n Rare (social use)

j k l m n Occasional (1x/week)
j k l m n
Frequent Average packs/day ______

j k l m n Occasional
Frequent History of binge drinking

j k l m n Frequent

Page 5 of 11

Patient Name: _________________________

Family History
Condition Asthma Cancer Heart Disease Heart Attack Before Age 50 Stroke Depression Arthritis Reflux Diabetes Blood Clots History of Bleeding Overweight Obese Morbidly Obese Obesity Surgery Grandparents Mother Father Siblings Children

c d e f g
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c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

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c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

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Review of Systems

Cardiovascular Disease
c d e f g
Yes

c d e f g

No

HYPERTENSION*

c d e f g

Yes

c d e f g

No

ENLARGED HEART BY ULTRASOUND*

c d e f g Borderline, no medication c d e f g Diagnosed but not on medication

if yes

Shortness of breath:

c d e f g (Class I) With exercise

if yes

c d e f g Treatment with a single medication c d e f g Treatment with multiple medications c d e f g Poorly controlled by medications

c d e f g (Class II) With ordinary activity c d e f g (Class III) Walking less than 1 block c d e f g (Class IV) At rest

c d e f g

Yes

c d e f g

No

ISCHEMIC HEART DISEASE*

c d e f g

Yes

c d e f g

No

ARRHYTHMIA

c d e f g Abnormal EKG, no active ischemia

if yes

c d e f g Occasional skipped beats by EKG or other test

if yes

c d e f g History of heart attack or anti-ischemia

medication

c d e f g Episodes of fast heartbeat without exercise,

by EKG or holter monitor test

c d e f g PCI or CABG surgery c d e f g c d e f g

Yes Active ischemia

c d e f g c d e f g

Atrial fibrillation Pacemaker

c d e f g c d e f g c d e f g

No

ADDITIONAL HEART PROBLEMS AND CORONARY ARTERY DISEASE

Heart bypass Heart stent (coronary artery stent) (list type of valve:

c d e f g c d e f g c d e f g

Medication for angina (ischemia) Blood thinner for heart Oxygen for heart or lungs

if yes

c d e f g Heart valve problem or replacement

________________________________________ )

Page 6 of 11

Patient Name: _________________________

c d e f g

Yes

c d e f g

No

DEEP VEIN BLOOD CLOT OR PULMONARY EMBOLISM*

c d e f g

Yes

c d e f g c d e f g c d e f g c d e f g

No

LEG EDEMA*

c d e f g c d e f g
c d e f g
if yes

Clinical suspicion but unconfirmed DVT associated with a risk factor (trauma or surgery) but resolved with blood thinning medication Recurrent DVT with long-term blood thinning medication Previous blood clot to lungs Recurrent pulmonary embolism, disability and decreased function, or past hospitalization if yes

Intermittent lower extremity edema, not requiring medical treatment Symptoms requiring medical treatment, diuretics, elevation, or a support base Stasis dermatitis, pigmentation, or cellulitis (legs swelling all of the time or at the end of the day) Stasis ulcers Disability, decreased function, or past hospitalization

c d e f g c d e f g

c d e f g c d e f g

c d e f g Vena Cava filter

c d e f g

Yes

c d e f g

No

PERIPHERAL VASCULAR DISEASE*

c d e f g

Yes

c d e f g c d e f g

No

ANGINA ASSESSMENT*

c d e f g c d e f g
if yes

Asymptomatic with bruit Claudication, anti-ischemic medication Mini-stroke Procedure for peripheral vascular disease Stroke or loss of tissue due to ischemia if yes

Chest pain with extreme exercise (e.g., running) Chest pain with moderate activity Chest pain with minimal activity or at rest Unstable angina

c d e f g c d e f g c d e f g

c d e f g c d e f g c d e f g

c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

Yes Yes Yes Yes Yes Yes Yes

c d e f g
c d e f g

No No No No No No No

HAVE YOU HAD A SUPERFICIAL VEIN BLOOD CLOT OR PHLEBITIS? HAVE YOU HAD MULTIPLE MISCARRIAGES? DO YOU TAKE BIRTH CONTROL MEDICATION OR ESTROGEN? DO YOU TAKE BLOOD THINNING MEDICATION? DO YOU HAVE LUPUS ANTICOAGULANT? DO YOU HAVE FACTOR V LEIDEN DISORDER? DO YOU HAVE AN ABNORMALITY IN PROTEIN C or PROTEIN S?

c d e f g
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c d e f g
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c d e f g

Endocrine Disease
c d e f g
Yes

c d e f g c d e f g c d e f g c d e f g

No

GLUCOSE METABOLISM*

c d e f g

Yes

c d e f g
c d e f g c d e f g c d e f g

No

DYSLIPIDEMIA* (elevated cholesterol/triglycerides)

Elevated fasting glucose or borderline diabetes Diabetes, controlled with oral medication (not insulin) Diabetes, controlled by insulin Diabetes, controlled with oral and/or injectable medication (not insulin) Poorly controlled or severe complications (i.e., retinopathy, neuropathy, renal failure, blindness) that you take: _____ if yes

Present, no treatment required Controlled with lifestyle change, including Step 1 or Step 2 diet Controlled with single medication Controlled with multiple medications Not controlled

if yes

c d e f g c d e f g

c d e f g c d e f g

c d e f g Number of oral medications

Page 7 of 11

Patient Name: _________________________

c d e f g

Yes

c d e f g

No

POLYCYSTIC OVARIAN SYNDROME*

c d e f g

Yes

c d e f g c d e f g c d e f g

No

COLLAGEN VASCULAR DISORDERS

c d e f g c d e f g
if yes

No treatment Birth control pills/patch/ring or anti-androgen medication Metformin, Avandia, or Actos Combination therapy Infertility GOUT OR HYPERURICEMIA*

Scleroderma Lupus Rheumatoid arthritis Other: ______________________________

c d e f g c d e f g c d e f g

if yes

c d e f g c d e f g

c d e f g

Yes

c d e f g c d e f g c d e f g

No

Gout or hyperuricemia, no symptoms Gout or hyperuricemia, on medications Uric acid crystals in joints Destructive joints Disability, unable towalk

if yes

c d e f g c d e f g c d e f g

Respiratory Disease
c d e f g
Yes

c d e f g c d e f g

No

SLEEP APNEA*

c d e f g

Yes

c d e f g c d e f g c d e f g

No

OBESITY HYPOVENTILATION*

Sleep apnea symptoms, but a negative sleep study or study was not done but no oral appliance (CPAP)

Hypoxemia (low oxygen) or hypercarbia (high carbon dioxide) on room air Severe hypoxemia or hypercarbia Pulmonary hypertension Right heart failure Right heart failure and left ventricular dysfunction

c d e f g Sleep apnea diagnosis by sleep study,

if yes

c d e f g c d e f g c d e f g

Sleep apnea requiring oral appliance (CPAP) Sleep apnea with significant hypoxia or oxygen dependent Sleep apnea with complications (i.e., pulmonary hypertension) No HAVE YOU BEEN TESTED FOR SNORING?

if yes

c d e f g c d e f g c d e f g

c d e f g Bipap machine

c d e f g c d e f g

Yes

c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

Yes

No

CPAP USE

CPAP seting is 0-5 CPAP setting is 5-10 CPAP setting is 10-15 CPAP setting is greater than 15

if yes

c d e f g

Yes

c d e f g c d e f g c d e f g c d e f g

No

PULMONARY HYPERTENSION*

c d e f g

Yes

c d e f g c d e f g

No

ASTHMA*

Symptoms of PH (SOB, dizziness, fainting) Patient has a confirmed pulmonary hypertension diagnosis Patient is well-controlled on blood thinners and/or calcium channel blockers Patient is on stronger medications (not including oxygen)

Intermittent mild symptoms, no medication

c d e f g Symptoms controlled with oral inhaler c d e f g

if yes Well-controlled with ongoing daily medication Symptoms not well-controlled; patient using steroids or anticholinergics Hospitalized within the last 2 years; history of intubation Ever hospitalized for asthma

if yes

c d e f g

c d e f g c d e f g c d e f g

c d e f g Patient is on oxygen: ________ liters c d e f g

Patient has or needs a lung transplant

Page 8 of 11

Patient Name: _________________________ Gastrointestinal Disease

c d e f g
Yes

c d e f g c d e f g c d e f g c d e f g c d e f g

No

GERD*

c d e f g

Yes

c d e f g
c d e f g c d e f g c d e f g c d e f g c d e f g

No

CHOLELITHIASIS (GALLSTONES)*

Intermittent or variable symptoms; no medication Intermittent medication H2 blockers or over-the-counter antacids (Zantac, Pepcid, Tagamet) High-dose Proton Pump Inhibitor (Prevacid, Protonix, Nexium, Prilosec) Has been tested for GERD, has had pH probe or esophageal manometry, meets criteria for anti-reflux surgery, or has had prior surgery for GERD History of Nissen Fundoplication History of endoscopic plicator or stretta if yes

Gallstones with no symptoms Gallstones with intermittent symptoms Gallstones with severe symptoms Gallstones with complications requiring immediate surgery prior to gastric bypass History of cholecystectomy (gallbladder removal)

if yes

c d e f g

c d e f g c d e f g c d e f g

laparoscopic open

c d e f g c d e f g

History of cholecystectomy with ongoing complications not resolved

c d e f g Barrett's esophagus c d e f g
Yes

c d e f g
c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

No

ABDOMINAL HERNIA*

c d e f g

Yes

c d e f g
c d e f g c d e f g c d e f g c d e f g c d e f g

No

OTHER G.I. PROBLEMS

No hernia Asymptomatic hernia, no prior operation Symptomatic hernia with or without incarceration Successful repair Recurrent hernia or size > 15 cm Chronic evisceration through large hernia with associated complication or multiple failed hernia repairs No HIATAL HERNIA check if present

Rectal bleeding Changes in bowel movements Blood in stool Diarrhea Constipation

if yes

c d e f g Hemorrhoids c d e f g Date of last colonoscopy: ______________

c d e f g Yes
if yes

c d e f g
c d e f g c d e f g c d e f g

Small hernia Large hernia Difficulty swallowing LIVER DISEASE*

c d e f g

Yes

c d e f g

No

c d e f g c d e f g
if yes

Modest liver enlargement, normal liver function tests, fatty change Category 1 Modest or greater liver enlargement, elevated liver function test, fatty change Category 2 Moderate to marked liver enlargement, fatty change Category 3, mild inflammation, mild fibrosis Definite cirrhosis, NASH, liver dysfunction indicated by liver function test Liver failure, transplant indicated or done

c d e f g c d e f g c d e f g

Page 9 of 11

Patient Name: _________________________ Musculoskeletal Disease

c d e f g
Yes

c d e f g c d e f g c d e f g

No

BACK PAIN*

c d e f g

Yes

c d e f g
c d e f g c d e f g

No

JOINT PAIN*

Intermittent symptoms not requiring medical treatment Symptoms requiring non-prescription treatment Degenerative changes or positive objective findings, symptoms requiring narcotic treatment Meets criteria for surgical intervention Operation ineffective if yes

Pain with exercise

c d e f g Non-narcotic pain medication required

Pain with daily activities Surgical intervention required (i.e., arthroscopy) Awaiting or has received joint replacement or other disability

if yes

c d e f g c d e f g c d e f g

c d e f g c d e f g

Where?

c d e f g Hips

c d e f g Knees

c d e f g Ankles

FUNCTIONAL STATUS*

c d e f g

Yes

c d e f g c d e f g

No

FIBROMYALGIA*

c d e f g c d e f g
check your status

Able to walk 200 feet unassisted Able to walk 200 feet with assistance device (cane, walker) Unable to walk 200 feet with assistance device Unable to walk more than 10 feet with assistance if yes

Treatment with exercise

c d e f g Treatment with non-narcotic medications c d e f g Treatment with narcotics c d e f g c d e f g

Surgical intervention done or recommended Disabling; treatment not effective

c d e f g c d e f g

c d e f g Motorized wheelchair c d e f g
Bedridden

Genitourinary and Reproductive

c d e f g
Yes

c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

No

URINE LEAKAGE WHEN LAUGHING, COUGHING, OR SNEEZING*

OTHER GENITOURINARY PROBLEMS

Minimal and intermittent Frequent but not severe Daily occurrence, requires sanitary pad Disabling Operation ineffective check if present

c d e f g c d e f g c d e f g c d e f g

Frequent urination Burning or painful urination Blood in urine Change in force of stream when urinating

if yes

c d e f g

Yes

c d e f g c d e f g c d e f g c d e f g c d e f g

No

MENSTRUAL IRREGULARITIES*

Irregular or infrequent periods Abnormally heavy or long periods No periods Prior total abdominal hysterectomy

if yes

Page 10 of 11

Patient Name: _________________________ Neurological

c d e f g
Yes

c d e f g

No

PSEUDOTUMOR CEREBRI*

OTHER NEUROLOGICAL PROBLEMS

c d e f g Headaches with dizziness, nausea,

and/or pain behind the eyes

c d e f g c d e f g c d e f g
check if present

Tremors Seizures or convulsions Stroke Paralysis Headaches Numbness or tingling sensation

c d e f g Headaches and visual symptoms c d e f g Patient has had an MRI to confirm

if yes PTC and is well-controlled with oral diuretics stronger medications

c d e f g c d e f g c d e f g

c d e f g Patient is well-controlled with c d e f g Patient has had or needs a

surgical intervention (i.e., a shunt)

Skin
c d e f g
Yes

Hematologic/Lymphatic
HEMATOLOGIC AND LYMPHATIC ISSUES

c d e f g
c d e f g c d e f g

No

ABDOMINAL SKIN OR PANNUS*

Rash in skin folds Abdominal skin that interferes with walking Recurrent cellulitis and skin ulcers Presence of flesh-eating bacteria, or surgical treatment required check if present

c d e f g c d e f g c d e f g c d e f g c d e f g

Slow to heal cuts; bruising Anemia Phlebitis Past transfusion Enlarged glands

if yes

c d e f g c d e f g

c d e f g Bleeding problem other than menses

Psychiatric
CONFIRMED MENTAL HEALTH DIAGNOSIS*

c d e f g

Yes

c d e f g c d e f g

No Mild

DEPRESSION*

c d e f g c d e f g c d e f g c d e f g c d e f g
if yes

Presently seeing a mental health professional Memory loss or confusion Suicidal tendencies Nervousness Insomnia Schizophrenia Bipolar disorder Depression Anxiety/panic disorder Personality disorder Psychosis Other: _________________________ Hospitalized for mental illness if yes

c d e f g Moderate, accompanied by some impairment, may require treatment c d e f g Moderate with significant impairment, treatment indicated

c d e f g Severe, definitely requiring intensive treatment c d e f g

Severe, requiring hospitalization

c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

PSYCHOSOCIAL IMPAIRMENT*

c d e f g c d e f g c d e f g c d e f g c d e f g c d e f g

No impairment Mild impairment in psychosocial functioning but able to perform all primary tasks Moderate impairment in psychosocial functioning but able to perform most primary tasks Moderate impairment in psychosocial functioning and unable to perform most primary tasks Severe impairment in psychosocial functioning and unable to perform most primary tasks Severe impairment in psychosocial functioning and unable to function

Page 11 of 11