• New Patient In-Take Form

  • Medical & Mental Health History

    Congratulations on taking the next step in improving your health! We welcome you to our program and thank you for completing the attached questionnaire to the best of your ability. Please bring this to your first appointment, we look forward to serving you! If you have any questions, please don’t hesitate to call our office: 208-782-3993

  • General Information

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  • Emergency Contact

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  • Gaurantor

    *ONLY complete these section is patient is under 18
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  • What Part of Our Program Are You Interested In?



  • Social History

  • Education


  • Smoking History


  • Alcohol Use

  • Other Substances

  • What Are Your Goals?

    Select All that Apply

  • Family History

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  • Personal Medical Care:

  • Please list any providers that contribute to your care:

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  • Medications / Allergies:

  • Please include any medications that are only taken as needed.

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  • Please list any medications you are currently taking to treat mental health issues. Also include any medications that you previously took and stopped.

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  • Weight Loss History:

  • Accurate history of previous attempts at weight loss are very important in obtaining insurance approval for surgical or non-surgical weight loss. Do your best to provide as much information as possible:

  • Physician or Dietitian Supervised Weight Loss

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  • Weight Loss History:

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  • No, please skip to next section

  • Past Surgical History:

  • None, please skip to the next section

    *Please include any endoscopy procedures (EGDs)

     

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  • Cancer Prevention Screening:

  • None, please skip to the next section

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  • Obstetric & Gynecology History:

    *THIS SECTION IS FOR FEMALE PATIENTS ONLY
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  • Current Health History:

  • Please indicate if you have experienced any of these issues in the past 60 days:









  • Weight Related Chronic Illness:

  • Please indicate any medical issues that you are currently treating or have treated in the past. These are very important to insurance companies and also to your safety in undergoing surgery.

  • Do you experience any of the following:


  • Cholesterol

  • High Blood Pressure

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  • Lung Disease

  • Thyroid Disease

  • Urinary Disease

  • Irritable Bowel

  • Blood Clots

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  • Insulin

  • Diabetes

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  • Obstructive Sleep Apnea

  • If you haven't been diagnosed please complete our sreening in the next section.

  • Sleep Apnea Screening

    *Only Complete this Page if you have not been diagnosed with sleep apnea
  • How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you have not done some of these things recently, try to work out how they would have affected you.

  • Epworth Sleepiness Scale:

  • 0 = no chance of dozing

    1 = slight chance of dozing

    2 = moderate chance of dozing

    3 = high chance of dozing

    Please use the above scale to choose the most appropriate number for each situation.

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  • Gastroesophageal Reflux Disease (GERD or Heartburn)


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  • Psychological

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  • Should be Empty: