Registration & HPI for Weight Loss with Dr. Sachin Kukreja, Dr. Elizabeth Hooper, and Dr. Rebecca Barr

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

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
2. Full Name

First NameLast Name
Relationship
Phone Number

Area CodePhone 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.)*

YesNo

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

YesNo
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 NameLast Name
Relationship
2. Name

First NameLast Name
Relationship

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.

Attestation
Name*

First NameLast Name
Date*

MonthDayYear
Date
Name of Personal Representative Authority (if someone other than the patient is completing the form)

First NameLast Name
Description/Relationship with Personal Representative Authority
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:

	YES	NO
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

	YES	NO
Have you ever been in treatment for the above disorder?
Do you believe you still have a problem with this disorder?

	0	1	2	3	4	5
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?

	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
Elevated A1c (Prediabetes)
Diverticulitis
Illicit Drug Use (kind and route)
Emphysema
Endometriosis
Fatty Liver Disease
Fibromyalgia
Gallstones or Gallbladder Sludge
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
Liver Disease
Lower Back Pain
Lung Disease
Lupus
Mental Illness
MI/Heart Attack
Migraines
Neuropathy
Plantar Fasciitis
Polycystic Ovarian Syndrome
Shortness of Breath
Sleep Apnea
Stomach Ulcer
Stroke
Venous Stasis Disease

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).