madisonaki

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:
First Name:*
Last Name:*
Age:*
Date of Birth: dd/mm/year*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Phone Number: *
SS#*
Race:*
Ethnicity:*
Religion:
Preferred Language:
Emergency Contact:
Emergency Contact Full Name: *
Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:*

MonthDayYear
Date
Relationship to You*
Program:
What Part of the Program Interests You? Check all that apply:*

Surgical Weight LossSleeveBypassBand RemovalNon-Surgical Weight LossOther
Social History:
Name of Employer:*
Employer Phone Number:
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Status:*

Full TimePart Time
Does your work require travel?*

YesNo
Which best describes you:

UnemployedSelf EmployedStay at Home ParentOn Active Military DutyRetiredStudentDisabled
Disabled Due to:
If Unemployed, Currently Looking for Work?

YesNo
Marital Status*

SingleMarriedDivorcedWidowed
Smoking History:
Are You Currently Using Nicotine:*

No, skip to next sectionFormer SmokerYes
If former smoker, quit date:

MonthDayYear
Date
If yes to using nicotine, which type:

CigarettesVapingChewing TobaccoOther
Do you understand that you must be free of nicotine at least 6 weeks prior to weight loss surgery?

YesNo
Would you like assistance to quit nicotine?

YesNo
Alcohol Use
Are You Currently Using Alcohol?*

No, skip to next sectionYes
If Yes: How many drinks per week, on average?

1-34-6More than 6
Other Substances
Are you currently using recreational or illicit drugs?*

No, skip to next questionYes
If Yes: What kind?
How often
Family History
Do not know family history, skip to next section:

Please fill out as much as possible:

	Living (Y/N)	Deceased Age	Cause of Death	Overweight or Obese (Y/N)	Mental Health Issues (Y/N)
Mother
Father
Sibling 1
Sibling 2
Sibling 3

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

High Blood PressureHeart DiseaseStrokeBleeding disorder (bloodclots, pulmonary embolism)DiabetesHigh CholesterolCancerLung Disease, AsthmaKidney DiseaseOther
If checked cancer, what type:
Medication and Allergies
Preferred Pharmacy / City*

Medications: (Include ALL Prescriptions, Vitamins, Supplements, and/or Over the Counter):

	Name of Drug:	Dose:	How Often:	Reason for use:
1
2
3
4

Do you have allergies?*

None, skip to next sectionYes

Please list Allergies to Medications:

	Name of Drug:	Reaction:
1
2
3
4

	Name:	Start Date:	End Date:	Amount of Weight Lost:	Did you Regain Weight? (Y/N)
1
2
3
4

	Name of Medication:	Start Date:	End Date:	Amount of Weight Lost:	Did you Regain Weight: (Y/N)
1
2
3

	Date:	Location:	Weight at time of surgery:	Lowest Weight Achieved:	Complications:
Gastric Bypass (Open or Laparoscopic)
Sleeve (Open or Laparoscopic)
Lap Band
Other

	Year:	Weight at Start of Pregnancy:	Weight at Delivery:
Pregnancy 1
Pregnancy 2
Pregnancy 3
Pregnancy 4
Pregnancy 5

	Chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (movie theatre, etc)
As a passenger in a car over an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (without alcohol)
In a car, while stopped for a few minutes in traffic

Empower New Patient Intake Form

Emergency Contact:

Program:

Social History:

Smoking History:

Alcohol Use

Other Substances

Family History

Medication and Allergies

Weight Loss History

Past Surgical History

This Section is For Female Patients ONLY

Current Health History

Weight Related Chronic Illness

Musculoskeletal

Cholesterol

High Blood Pressure

Liver Disease

Heart Disease

Lung Disease

Thyroid Disease

Blood Clots/Bleeding Disorders

Insulin Resistance (Pre-Diabetes)

Diabetes

Obstructive Sleep Apnea

Sleep Apnea Screening

Gastroesophageal Reflux Disease

Psychological

	yes/no
Do you snore loudly?
Do you often feel tired, fatigued or sleepy during the day?
Has anyone observed you stop breathing during sleep?
Do you have or are you being treated for high blood pressure

	Surgery:	Date:	Open or Minimally Invasive:
1
2
3
4