Medical History Form

Personal Data

First Name

Last Name

Gender

E-Mail

Cell Phone

Home Phone

Address

County

State

City

Zip / Postal Code

Date of Birth

Weight in Pounds

Height (Feet)

Height (Inches)

BMI

Emercency Contact's Name

Emergency Contact's Phone Number

Emergency Contact's Relationship To You

Occupation

Employer*

Employer's Phone Number

Education

Who referred you to unsfooter-sticky?

*Optional

Weight Loss

Have you ever had surgery for weight loss?

YES NO

What surgery did you have if applicable?

Surgeon's name if applicable

Date of surgery if applicable

Have you ever seen a doctor about weight loss surgery?

YES NO

Doctor's name if applicable

Type of surgery consulted about if applicable

Date of consultation if applicable

*Optional

Past Surgical History and Medication

Past Surgical History

Please list any and all surgeries you have had including TYPE OF SURGERY, NAME OF SURGEON, NAME OF HOSPITAL, and DATE of surgery (please be as complete as possible)

Please list any and all medications you are currently taking, include NAME of the Medication, DOSE, HOW OFTEN you take the medication, and REASON for taking it.

Please list any and all ALLERGIES to medication, food, latex or anything else here. Also please include the type of reaction you have to the allergy.

Please list any and all diet programs you may have tried in the past, please include NAME of the program, WHEN and how long ago, TOTAL WEIGHT LOSS, and POUNDS REGAINED

*Optional

Daily Diet

PLEASE COMPLETE THE FOLLOWING FOOD DIARY AS HONESTLY AND COMPLETELY AS POSSIBLE. YOU WILL FILL IN TWO FIELDS, ONE FOR A NORMAL WEEKDAY DAY AND ONE FOR A NORMAL WEEKEND DAY. INCLUDE THE FOOD YOU EAT, AMOUNT OF FOOD YOU CONSUMED, AND HOW THE FOOD WAS PREPARED. INCLUDE SNACKS AND BEVERAGES (WITH AMOUNTS CONSUMED).

WEEKDAY DAY - pick an average day you live during the work week

WEEKEND DAY - describe what you eat over a typical weekend day

*Optional

Psychological General Well-Being Index (PGWBI)

This section of the examination contains questions about how you feel and how things have been going with you. For each question select the answer which best applies to you.

How have you been feeling in general? (during the past month)

How often were you bothered by any illness, bodily disorder, aches or pains? (during the past month)

Did you feel depressed? (during the past month)

Have you been in firm control of your behavior, thoughts, emotions, or feelings? (during the past month)

Have you been bothered by nervousness or your "nerves" (during the past month)

How much energy, pop, or vitality did you have or feel? (during the past month)

I felt downhearted and blue (during the past month)

Were you generally tense or did you feel any tension? (during the past month)

How happy, satisfied, or please have you been with your personal life (during the past month)

Did you feel healthy enough to carry out things you like to do or had to do? (during the past month)

Have you felt so sad, discouraged, hopeless, or had so many problems that you wondered if anything was worthwhile? (during the past month)

I woke up feeling fresh and rested (during the past month)

Have you ever been concerned, worried, or had any fears about your health? (during the past month)

Have you had any reason to wonder if you were losing your mind, or losing control over the way you act, talk, think, feel or of your memory? (during the past month)

My daily life was full of things that were interesting to me (during the past month)

Did you feel active, vigorous, or dull, sluggish? (during the past month)

Have you been anxious, worried, or upset? (during the past month)

I was emotionally stable and sure of myself (during the past month)

Did you feel relaxed, at ease or high strung, tight, or keyed-up? (during the past month)

I felt cheerful, lighthearted (during the past month)

I felt tired, worn out, used up or exhausted (during the past month)

Have you ever been under or felt you were under any strain, stress or pressure (during the past month)

Legal

Now that you have completed the medical history form, please take a moment to look it over one last time before submitting the form. It is very important that the doctor's have a complete understanding of your health as they prepare for your surgery.

Please enter your name if everything is correct. *

Please enter today's Date*

I have read and agree to all of the terms set forth on the Legal Page

Weight Loss Surgery at Hidalgo Bariatrics

Personal Data

Family History

Weight Loss

Medical history

System Reviews

Please indicate if you have or have had any of the following conditions:

Cardiovascular

Respiratiry

Endocrine

Gastero-Intestinal

Bladder / Kidney

Musculoskeletal

Head and Neck

Neurologic

Skin

Blood

Ginecology
For women only. Men should skip it down to the next section of questions.

Breast
For women only. Men should skip it down to the next section of questions.

Psychiatric
All patients (men and women) must answer all questions

Constitutional

Tabacco use

Alcohol use

Caffeine use

Past Surgical History and Medication

Past Surgical History

Daily Diet

Psychological General Well-Being Index (PGWBI)

This section of the examination contains questions about how you feel and how things have been going with you. For each question select the answer which best applies to you.

Legal

Weight Loss Surgery at Hidalgo Bariatrics