General Surgery Consultation Intake Form

Sofiane El Djouzi, MD, MS, MBA, DABOM, FRCS(Eng), FACS, FASMBS

Bariatric & Metabolic Surgery

www.premierbariatricinstitute.com

info@premierbariatricinstitute.com

📞 773 365 1300

📠 773 365 1515

Office 1: 2821, 83rd St, Darien, IL 60561

Office 2: 420 S. Schmidt Rd, Suite 235, Bolingbrook, IL 60440
General Surgery Consultation Form
DATE
How did you hear about Dr. El Djouzi?
If referred by a physician, may we have their name?
What is the condition you are consulting for?
Patient Demographics
Last Name
First Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
What is your gender
Race
Let's calculate your body mass index (BMI)?
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is it permissible to leave you a message?
Emergency contact details
Primary care physician (PCP) contact information
CLICK TO TAKE A PHOTO OF YOUR INSURANCE CARD (FRONT)
CLICK TO TAKE A PHOTO OF YOUR INSURANCE CARD (BACK)
Can you provide the specifics of your primary insurance?
Do you have secondary insurance details to share? (Feel free to skip if it doesn't apply)
History Of Your Complaints
1. Can you describe your current symptoms and when they first began? Type a label
2. Do you experience any pain or discomfort? Yes No
3. If yes, can you describe its intensity, frequency, and location? Type a label
4. Are there any factors that worsen your symptoms, such as certain activities, foods, or positions? Type a label
5. Do you have any accompanying symptoms such as nausea, vomiting, fever, or changes in bowel movements? Type a label
6. Have you experienced any recent weight loss, fatigue, or other systemic symptoms? Type a label
7. What medications are you currently taking for your condition, including over-the-counter drugs and supplements? Type a label
Past Medical History

Check all that apply

STOP-Bang Questionnaire

Rows	Yes	No
Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?
Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
Do you have or are being treated for High Blood Pressure?
Is your BMI more than 35 kg/m2?
Are you older than 50 year old?
For male, is your shirt collar 17 inches/43 cm or larger? For female, is your shirt collar 16 inches/41 cm or larger?
Are you Male?

Low risk of OSA: Yes to 0-2 questions Intermediate risk of OSA: Yes to 3-4 questions High risk of OSA: Yes to 5-8 questions or Yes to 2 or more of 4 STOP questions + male gender Yes to 2 or more of 4 STOP questions + BMI > 35 kg/m2or Yes to 2 or more of 4 STOP questions + neck circumference (17”/43cm in male, 16”/41cm in female)
Respiratory System:
Cardiovascular System:
Endocrine and Metabolic System:
Cardiovascular System:
Cardiovascular System:
Reproductive System:
Renal/Urologic System:
Neurological System:
Psychiatric:
Dermatological:
Hematological:
Musculoskeletal and Connective Tissue:
DO YOU SUFFER FROM ANY DISABILITY
CAUSE OF DISABILITY
DO YOU USE ANY OF THE FOLLOWING?
Past Surgical History

Check all that apply
Have you encountered any complications or issues related to anesthesia?

Other
Home Medication

Check all that apply
Do you currently utilize any prescription medications?
Are you presently using oral contraceptives?
Please provide details of your medication, including dosage and how frequently you take it
Follow this format: [Medication: dose/frequency]
1. 
2. 
3.
Kindly enumerate any dietary supplements you might incorporate into your routine or if you do not take any write "N/A"
1. 
2. 
3.
Allergy

Check all that apply
Do you possess any allergies to the following substances?

Other
Social History

Check all that apply
Ethnicity
Marital Status
Spouse's/Partner’s Full Name
What degree or level of education have you achieved?
What is your current occupational status?
Can you comprehend, articulate, and converse proficiently in the English language?
If not, which language do you primarily utilize?
Kindly enumerate any communication obstacles you may encounter or specific accommodations you necessitate

Check all that apply

Rows	Yes	Never	I quit
Smoking Tobacco
Chewing Tobacco
Snuffing Tobacco
Smoking Marijuana
DrInking Alcohol
Consuming Illicit Drugs

How many cigarettes do you typically consume in a day?
For how many years have you been indulging in tobacco?
If you partake in alcohol, is it primarily in social settings?
If you partake in prohibited substances, which ones do you use?
Family Medical History

Check all that apply
Do you have siblings?
How many brothers?
How many sisters?
Any family medical history?

Other
Review Of Systems

Check all that apply
General

Other
Head & Neck

Other
Cardiovascular

Other
Respiratory
Endocrine

Other
Gastrointestinal

Other
Bladder/Kidney

Other
Breast

Other
Gynecologic (women only)

Other
Musculoskeletal

Other
Neurologic

Other
Psychiatric

Other
Blood/Lymphatic

Other
Low Platelets (thrombocytopenia)

Other
Skin

Other
Hernia(s)

Other
Chronic pain syndrome
If yes, where is pain?
⛔️ IMPORTANT NOTICE ⛔️

Make certain that all necessary fields of this intake form have been duly completed. Once you have cross-checked all details, kindly proceed by pressing the green button below to finalize your submission. Should there be any oversight, a red flag will manifest, signaling an incomplete section that requires your attention.s to be filled out.

General Surgery Consultation Form

Patient Demographics

History Of Your Complaints

Past Medical History

Past Surgical History

Home Medication

Allergy

Social History

Family Medical History

Review Of Systems

Objective

Assessment

Surgery Plan

Preoperative Plan