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

    • Patient Information 
    • Date of Birth*
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    • Sex*
    • Ethnicity*
    • Race*

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    • Pharmacy Information 
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    • Primary Insurance 
    • Are you using insurance or self paying?*
    • Insurance Company Name

    • Please remember to provide a copy of your Drivers License and Insurance card to the office if you haven't already. You may text it to 469-620-0222.

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    • Who is the primary insured party?*

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    • Patient's Relation to Insured Party

    • Secondary Insurance 
    • Do you have secondary insurance?
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    • Who is the secondary insured party?

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    • Patient's Relation to Insured Party

    • Medicare 
    • Do you have Medicare?
    • Are you a resident at:
    • Admit Date
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    • Authorization and Acknowledgement 

    • Please list the people with whom we can discuss your care and leave messages.

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

    • 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:

    • Your Doctors 

    • Please let us know of all the doctors you see.

    • Primary Care Doctor*
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    • Referring Doctor
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    • Cardiologist
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    • Gastroenterologist
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    • Orthopedic Surgeon
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    • Dietary History 
    • Rows
    • Rows
    • Rows
    • Who does the grocery shopping in your home?*
    • Who does the cooking in your home?*
    • Weight History 
    • My support in my weight loss journey comes from my:*
    • You are seeking weight loss because: (select all that apply)*

    • My Current Weight is the heaviest I've been*
    • Rows
    • FEMALE PATIENTS ONLY: I am premenopausal and still have my uterus/ovaries
    • FEMALE PATIENTS ONLY: I plan for children in the future
    • If Yes to Above, which of the above medications have you tried (ok to select multiple)?
    • Sleep History 
    • Have you been diagnosed with SLEEP APNEA SYNDROME?*
    • Rows
    • Do you have or have you ever had: (check all that apply, 1 point for each)*

    • Office Use: STOP BANG Score (3-4 = Intermediate Risk, > 5 = High Risk):

    • GERD HQRL Scale 
    • Rows
    • How satisfied are you with your present condition of GERD?*
    • Are you currently taking any medications for heart burn or GERD?*
    • Please select all medications that you are taking or have taken:

    • Patient Medication Information 
    • Rows
    • Patient Medical History 
    • Rows
    • Allergy Information 
    • Rows
    • Rows
    • Are you a Jehovah's witness and refuse blood transfusions in an emergent or life-threatening situation?
    • Surgical History 
    • Rows
    • Family History 
    • Rows
    • Social History 
    • Marital Status
    • Tobacco Use*
    • Do you use alcohol?*
    • Do you use recreational drugs?
    • Have you ever been treated for narcotic dependency?
    • Review of Systems 

    • Please check all symptoms you currently experience, or have experienced in the past year:

    • General
    • HEENT
    • Endocrine
    • Respiratory
    • Cardiovascular
    • Gastrointestinal
    • Reproductive (Females)
    • Genitourinary
    • Musculoskeletal
    • Neurological
    • Psychological
    • Taking Birth Control? (Females)
    • Taking Hormone Replacements? (Females)
    • Health Screening 
    • Please select one:
    • Attestation 
    • Date*
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    • 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).

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