• Empower New Patient Intake 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. If you have any questions, please don't hesitate to call our office: (208) 782-3993

  • General Information: 

  • Format: (000) 000-0000.

  • Emergency Contact:

  • Format: (000) 000-0000.
  • Birthdate:*
     - -

  • Program:

  • What Part of the Program Interests You? Check all that apply:*

  • Social History:

  • Format: (000) 000-0000.
  • Work Status:*
  • Does your work require travel?*
  • Which best describes you:
  • If Unemployed, Currently Looking for Work?
  • Marital Status*

  • Smoking History:

  • Are You Currently Using Nicotine:*
  • If former smoker, quit date:
     / /
  • If yes to using nicotine, which type:
  • Do you understand that you must be free of nicotine at least 6 weeks prior to weight loss surgery?
  • Would you like assistance to quit nicotine?

  • Alcohol Use

  • Are You Currently Using Alcohol?*
  • If Yes: How many drinks per week, on average?

  • Other Substances

  • Are you currently using recreational or illicit drugs?*

  • Family History

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  • Please indicate if you have a family history of: (check all that apply)

  • Medication and Allergies

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  • Do you have allergies?*
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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:

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  • Past Surgical History

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  • This Section is For Female Patients ONLY

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  • Do you currently use birth control?
  • Do you plan on becoming pregnant in the future?

  • Current Health History

    Please indicate if you have experienced any of these issues in the past 60 days
  • Head, Eye, Ear, Nose, Throat*
  • Heart*
  • Lungs*
  • Gastrointestinal*
  • Kidney/Bladder*
  • Neurological*
  • General*
  • Mental Health*

  • 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.

     

  • Musculoskeletal

  • Do you experience any of the following:
  • Do you require assistance to walk?
  • Do you experience swelling in your legs?

  • Cholesterol

  • Have you been diagnosed with elevated cholesterol or triglycerides?

  • High Blood Pressure

  • Have you been diagnosed high blood pressure?

  • Liver Disease

  • Have you been told you have abnormal liver function?
  • Have you been diagnosed with fatty liver?
  • If yes, how was it diagnosed?

  • Heart Disease

  • Have you been diagnosed with any of the following?
  • Date of heart attack
     - -

  • Have you had recent cardiac testing? 

  • Date of Stress Test
     - -
  • Date of Echocardiogram
     - -
  • Are you currently on blood thinners for a heart condition?

  • Lung Disease

  • Do you get shortness of breath with normal activity?
  • Have you been diagnosed with asthma?
  • Have you been diagnosed with COPD?
  • Do you treat any lung condition with steroids?
  • Do you use supplemental oxygen?

  • Thyroid Disease

  • Have you been diagnosed with a thyroid condition?
  • If Yes:

  • Blood Clots/Bleeding Disorders

  • Do you have a history of blood clots?
  • If Yes: Date of DVT/PE
     - -
  • Have you been diagnosed with bleeding disorder?

  • Insulin Resistance (Pre-Diabetes)

  • Have you been diagnosed with insulin resistance?
  • If yes, how are you treating?

  • Diabetes

  • Have you been diagnosed with diabetes?
  • If yes, what type?
  • How is your diabetes treated?
  • If with medication, how many medications are used
  • Do you use insulin to treat your diabetes?
  • Do you have complications from your diabetes?
  • If yes, choose one of the following:

  • Obstructive Sleep Apnea

  • Have you been diagnosed with sleep apnea? If no, please complete questions in next section.
  • Do you use any of the following
  • Do you use medication to help with sleep?

  • Sleep Apnea Screening

  • 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.

     

    Epwroth 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

  • Have you been diagnosed with heartburn?
  • If yes, how are you treating it?
  • Have you had an endoscopy for heartburn?
  • Have you been diagnosed with hiatal hernia?
  • Have you been diagnosed with Barrett's esophagus?
  • Have you had surgery for heartburn?
  • Have you been diagnosed with stomach ulcers?

  • Psychological

  • Do you have any history of:

  • Thank you for completeting the form! 

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