Advanced Laparoscopic Specialists

Health Questionnaire Form

Please Print

Date of Visit: _________

Name: _________________________ ____________________ ____

^{Last First MI}

Date of Birth____________________________ Social Security #_________________

Driver’s License #________________________ State_________

Address________________________________

City____________________________________ State________ ZIP________

Home Phone_____________________________ Mobile Phone__________________

E-mail__________________________________

Occupation______________________________ Employer_____________________________

Address_________________________________ Phone_________

Emergency Contact

Name___________________________ Relationship_________________

Address___________________________ Phone_____________________

Health Insurance

Principal Insurance Holder: □ Self □ Spouse □ Partner

^Name of Primary Health Insurance	^Subcriber^/Group ID Policy #
	^Subcriber^/Group ID Policy #
^Other Health Insurance	^Subcriber^/Group ID

Which physicians would you like us to contact regarding your treatment here?

Include the physician who referred you to us first please. (Please provide address and/or phone number if possible)

^Referring Name	^Address
^Primary Physician	^Address
^Other physician	^Address

Patient Signature _____________________________ Date_____________________

Medical History

Review of Systems

Do you currently have or have you in the past had any of the following?

Yes No Weight Loss Yes No Fevers

Yes No Shaking/Chills

Yes No Abdominal pain Yes No Nausea

Yes No Vomiting Yes No Heartburn

Yes No Difficulty swallowing Yes No Painful swallowing

Yes No Bleeding per rectum Yes No Black, tarry stools

Yes No Difficult/painful urination Yes No Blood in urine

Yes No Previous abdominal surgery Yes No Previous gallbladder surgery

Yes No Previous heart surgery Yes No Impotence

Yes No Kidney problems Yes No Urinary or prostate problems

Yes No Previous lung surgery Yes No Have you ever taken steroids (prednisone, etc?)

Yes No Previous organ transplant

Yes No Cancer Yes No Diabetes

Yes No High blood pressure Yes No Angina (chest pain)

Yes No Heart attack or heart disease (congestive heart failure)

Yes No Emphysema, Asthma or lung disease

Yes No Blood clots in legs Yes No Blood clots in lungs or heart

Yes No Have you ever taken a blood thinner like Coumadin (warfarin) or Heparin?

Yes No Liver disease or cirrhosis Yes No Alcoholism

Yes No Disease of the pancreas Yes No Gallstones

Yes No Jaundice (yellow skin) Yes No Stomach (gastric) or duodenal (peptic) ulcers

Yes No Hiatal hernia Yes No Diverticulitis

Yes No Other intestinal disease Yes No Thyroid problems

Yes No Anemia Yes No Do you take aspirin or ibuprofen

Yes No Easy bruising or bleeding Yes No Have you had a blood transfusion

Yes No Skin diseases Yes No Arthritis

Yes No Neurologic illness Yes No Psychiatric illness

Yes No Do you smoke now? If yes, how many packs per day? ______ for how many years? _______

Yes No Have you smoked in the past? If yes, how many packs per day?____ for how many years? ____

How long ago did you stop? _________

Yes No Do you drink alcohol?

Yes No Do you drink other than socially (not more than 1 drink per day on average). If yes, how many drinks do

you average per day? ______

Yes No Are you or have you been an IV drug user?

Yes No Are you currently employed? If yes, what type of work? _______________________________________

Yes No Are you exposed to any hazardous chemicals in your work or otherwise?

Family and Social History

Marital status: Single Married Divorced

Occupation__________________________________ Presently Employed/ Retired?___________________

Do you currently smoke cigarettes? Yes No How many packs/day? _______ For how long?_______

Do you Drink alcohol? Yes No How much? _______ For how long?_______

Is there any family history of:

Yes No Cancer Yes No Diabetes

Yes No Heart disease Yes No Asthma or Emphysema

Yes No Stroke Yes No Other serious health problems If yes, what are they? __________________________________________________________________________________________________

If either parent has died, mother’s cause of death was ________________________ at age _______in what year? _______

Father’s cause of death was _________________________ at age______ in what year? _______

FEMALE PATIENTS:

Date of last menstrual period:______ _____________________________

Are your menstrual periods regular?

Are you using birth control? If yes, what type:

Number of Pregnancies: Number of live births:

Children/Name & Age_______________________________________________________________

Other comments:

Medical and Surgical History

Please provide a list of your medical history

Type of illness

Physician

Additional Comments

Have you had any previous surgeries? Yes No

Previous Surgeries

Type of Surgery

Hospital/Location

Physician

Do you have any Food/Drug allergies? Yes No If yes, to what?____________________________________

Are you taking any medications? Yes No

Name of Medicine/Indication

Dosage

Frequency

NUTRITIONAL

Patient Name__________________ AGE________ Gender______ Date___________

Referred by____________________

Weight Reduction Programs

Current Weight_________ Weight 1 year ago________ Wt 5 year ago________

Previous Weight Reduction Efforts

Type of Program (Including Medications)

Year/Duration of effort

Weight Loss

Was all weight regained? (Yes Or NO)

Most Effective Program?_______________________________

Maximum Weight Loss Achieved?_____________________

List any program/effort monitored by a Physician_______________________________________________