Registration & HPI for Weight Loss with Dr. Sachin Kukreja

Patient History and Intake for Weight Loss
All fields with an asterisk must be completed for the form to submit. Thank you.

Pharmacy Information
Pharmacy Name
Pharmacy Address (if available, even street name and City is appreciated)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number

Primary Insurance
Are you using insurance or self paying?

Self Pay Insurance
Insurance Company Name
Claims Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Policy Number
Group Number
Employer Name
Employer Phone Number

Area Code Phone Number
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Who is the primary insured party?

Patient Responsible Party
Full Name

First Name Last Name
Date of Birth

Month Day Year
Social Security #
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Patient's Relation to Insured Party

Spouse Child

Secondary Insurance
Do you have secondary insurance?

Yes No
Insurance Company Name
Claims Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Policy Number
Group Number
Employer Name
Employer Phone Number

Area Code Phone Number
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Who is the secondary insured party?

Patient Responsible Party
Full Name

First Name Last Name
Date of Birth

Month Day Year
Social Security #
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Patient's Relation to Insured Party

Spouse Child

Medicare
Do you have Medicare?

Yes No
Are you a resident at:

Skilled Nursing Facility Rehab Facility N/A
Admit Date

Month Day Year
Date
Name of Facility
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Authorization and Acknowledgement
Please list the people with whom we can discuss your care and leave messages.
1. Full Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
2. Full Name

First Name Last Name
Relationship
Phone Number

Area Code Phone Number
May we leave messages on your answering machine regarding your care? (Please understand that if we cannot leave messages, it is your responsibility to initiate contact with us regarding follow-up of labs, appointment, etc.)

Yes No

Release of Medical Records
Social Security #
Restriction List:

Notice of Privacy Practices
Authorization List - Do you have anyone you want to receive information from our office, on your behalf? *

Yes No
The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for DFW Bariatrics and General Surgery to share my protected health information with:
1. Name

First Name Last Name
Relationship
2. Name

First Name Last Name
Relationship

Weight History
What has been your heaviest weight? (lbs) *
When? *
What is the least you weighed as an adult? (lbs) *
When? *
You are seeking weight loss because: (select all that apply) *

Improved quality of life Become healthier Treat diabetes Treat hypertension Treat sleep apnea Improve eligibility for kidney transplantation
My support in my weight loss journey comes from my: *

Spouse Parents Children Friends None

My weight in these years, was: *

Weight

2016

2017

2018

2019

2020

Current height in inches (ie: 5 ft 4" or 64") *

Dietary History
Age you started seriously dieting *

Please identify the diets and diet programs you tried, if any:

Yes

Dates

Duration

MD Supervised

Max Weight Loss

Jenny Craig

Nutri-System

Weight Watchers

OptiFast

Fen/Phen

Phentermine

Meridia

Atkins Diet

Metabolife

Ideal Protein

Self-Created Diet

Other

Present or past history of eating disorder? *

YES

Anorexia – fear of weight gain leading to malnutrition and usually excessive weight loss

Bulemia – overeating following by vomiting, laxative/diuretics abuse and/or excessive exercise

Binge Eating Disorder – consuming a large quantity of food in a short period of time

Night Eating Disorder – eating very late at night, waking up in the middle of the night to eat

If you answered YES to any of the above questions:

YES

Have you ever been in treatment for the above disorder?

Do you believe you still have a problem with this disorder?

Who does the grocery shopping in your home?

Self Someone else
Who does the cooking in your home?

Self Someone else
How many meals do you eat per day?
How many meals do you eat OUTSIDE the home PER WEEK?

Sleep History
Have you been diagnosed with SLEEP APNEA SYNDROME? *

YES NO

Do you have or have you ever had: (check all that apply, 1 point for each) *

Snore loudly (louder than talking or loud enough to be heard through closed doors Often feel tired, fatigued, or sleepy during the day Others have observed you stop breathing during your sleep High Blood Pressure BMI > 35kg/m2 Age > 50 Neck > 17” (men), > 16” (women) Male None Apply to Me
Office Use: STOP BANG Score (3-4 = Intermediate Risk, > 5 = High Risk):

GERD HQRL Scale

GERD HQRL Scale

How bad is your heartburn?

Do you have heartburn while lying down?

Do you have heartburn after meals?

Does heartburn change your diet?

Does heartburn wake you from sleep?

Do you have difficulty swallowing?

Do you have pain with swallowing?

If you take medication, does it affect your daily life?

How satisfied are you with your present condition?

Satisfied Dissatisfied
Are you currently taking any medications for heart burn or GERD?

Yes No
Please select all medications that you are taking or have taken:

Nexium Prilosec Prevacid Aciphex Protonix Zegrid Kapidex Dexilant Vimovo

Patient Medication Information

List Your Medications Below (if appropriate, may list NONE under first row) *

Medication (Prescription and over the counter)

Strength

Frequency

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8

Medication 9

Medication 10

If you have other medications you are taking, please list the name, strength, and frequency of each, below.

List Your Medication ALLERGIES Below (if appropriate may list None on first row) *

Medication (Prescription and over the counter)

Type of Reaction(s)/Symptom(s)

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8

Medication 9

Medication 10

If you have other medication allergic reaction(s)/symptom(s), please list the name of the medication and the reactions/symptom(s) to each, below.

Are you allergic to the below items? *

Yes

Latex

Iodine

Surgical Tape

Surgical Adhesive

Shellfish

Patient Medical History

Medical Condition

Current

Past

AIDS

Alcohol Abuse

Allergies (Seasonal)

Anemia

Angina

Anxiety

Arthritis

Asthma

Bleeding Abnormality
including hemophilia

Blood Clots

Colitis

Crohn's Disease

Deep Vein Thrombosis (DVT)
or Pulmonary Embolism (PE)

Depression

Diabetes Type I

Diabetes Type II

A1c

Diverticulitis

Drug Use (kind and route)

Emphysema

Endometriosis

Epilepsy

Fatigue

Fatty Liver Disease

Fibromyalgia

Gallbladder Disease

GERD

Gestational Diabetes

Gout

Hashimoto's Disease

Heart Disease

Heart Palpitations

Heart Murmur

Hemorrhoids

Hepatitis A

Hepatitis B

Hepatitis C

Hernia (s)

High Blood Pressure

High Cholesterol

High Triglycerides

Hyperthyroidism (Graves Disease)

Hypothyroidism

Incontinence

Infertility

Irregular Menses/Period

Irritable Bowel Syndrome

Kidney Disease

Kidney Stones

Liver Disease

Lower Back Pain

Lung Disease

Lupus

Mental Illness

MI/Heart Attack

Migraines

Neuropathy

Plantar Fasciitis

Polycystic Ovarian Syndrome

Rheumatic Fever

Shortness of Breath

Sleep Apnea

Stomach Ulcer

Stroke

Venous Stasis Disease

Surgical History

Type of Surgery (if appropriate, put None in the first row) *

Type of Surgery

Date of Surgery

Surgery 1

Surgery 2

Surgery 3

Surgery 4

Surgery 5

Surgery 6

Surgery 7

Surgery 8

Family History

Answer all that apply:

Relationship to Patient

Alcohol

Anemia

Bleeding Tendency/Blood Disorder

Bowel Problems

Breast Cancer

Cancer

Colon Cancer

Depression

Diabetes

Drug Use

DVT

Gallbladder Problems

Heart Disease

High Blood Pressure

High Cholesterol

Kidney Disease

Liver Disease

Lung Disease

Mental Illness

Migraines

Obesity

Polycystic Ovarian Syndrome

Stroke

Thyroid Disease

Health Screening
Year of last mammogram: (if applicable)
Year of last colonoscopy:
Please select one:

Colonoscopy was normal Colonoscopy was abnormal

Attestation
Name

First Name Last Name
Date

Month Day Year
Date
Description of Personal Representative Authority (if someone other than the patient is completing the form)
Signature

Clear
Please note that all portions with an asterisk must be completed for the form to submit. You will be directed to a thank you page upon submission. If you do not see the page, the form was not submitted due to an error (likely a mandatory field was not completed).
Should be Empty:

Patient History and Intake for Weight Loss

All fields with an asterisk must be completed for the form to submit. Thank you.

Please note that all portions with an asterisk must be completed for the form to submit. You will be directed to a thank you page upon submission. If you do not see the page, the form was not submitted due to an error (likely a mandatory field was not completed).