Premier Bariatric Institute I General Surgery 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
Date
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.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is it permissible to leave you a message?*

Yes with CellYes with Email
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*

	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*

YesNo
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?*

N/A (if you have never had surgery)NoneExcessive nauseaVomitingCardiac issuesWoke up during the procedurestopped breathingDifficulty waking upDifficulty urinatingOther
Home Medication

Check all that apply
Do you currently utilize any prescription medications?*

YesNo
Are you presently using oral contraceptives?*

YesNoN/A (for male patient)
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?*

NoneLatexTape (adhesives)PenicillinSulfa drugs (sulfonamides)Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs): Such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn)Antiseizure medications: Drugs such as phenytoin (Dilantin, Phenytek) and carbamazepine (Tegretol, Carbatrol).Chemotherapy drugs: These drugs are used to treat cancer and can sometimes cause allergic reactions.Monoclonal antibody therapy: Examples include rituximab (Rituxan) and trastuzumab (Herceptin).ACE inhibitors: Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril), and ramipril (Altace).Radiocontrast media: These are dyes used in some imaging tests.Local anesthetics: Such as procaine, lidocaine, and benzocaine.Opiates: Morphine, codeine, and other related drugs.Vaccines: Some individuals might be allergic to components of vaccines, like gelatin or egg protein.Muscle relaxants: Used during general anesthesia.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?*

YesNo
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*

	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?*

YesNoI refrain from drinking alcohol.
If you partake in prohibited substances, which ones do you use?
Family Medical History

Check all that apply
Do you have siblings?*

YesNo
How many brothers?
How many sisters?
Any family medical history?*

NoneObesityCancerDiabetes MellitusHigh Blood PressureCardiac DiseaseCOPDAsthmaHistory of Sdden DeathOther
Review Of Systems

Check all that apply
General*

NoneFeversWeight GainTired / No EnergyNight SweatsInsomniaHair LossAppetite ChangeOther
Head & Neck*

NoneGlaucomaWear contacts / glassesBlurred / Double VisionVision ProblemsHearing ProblemsRegular Ear InfectionsSinus DrainageNose BleedsHoarsenessDentures, Partial / FullAllergiesOther
Cardiovascular*

NoneHeart AttackChest Pain w/ ActivityRhythm ChangesCongestive Heart FailureHigh Blood PressurePalpitationsVaricose VeinsDyspnea on ExertionAnkle SwellingAnkle / Leg UlcersElevated TriglyceridesPhlebitis / DVTClogged Heart ArteriesRheumatic Fever / Valve Damage / MVPRapid Heart BeatIrregular Heart BeatCramping in legs when walkingHeart MurmurAtrial FibrillationElevated CholesterolOther
Respiratory*

NoneAsthmaEmphysema / COPDBronchitisPneumoniaChronic CoughShortness of Breath at RestUse of Cpap / BipapUse of OxygenSnoringPulmonary EmbolismSleep ApneaOther:
Endocrine*

NoneParathyroidHypothyroidGoiterLow Blood SugarExcessive ThirstEndocrine Gland TumorPre DiabetesDiabetes (Diet or Pills)Diabetes (Insulin Shots)Abnormal Facial HairExcessive UrinationGoutOther
Gastrointestinal*

NoneHiatal HerniaBlood in StoolIrritable Bowel SyndromeHemorrhoidsBlack, Tarry StoolEnlarged LiverJaundiceGERDHeartburnUlcersDiarrheaHistory of Elevated Liver EnzymesConstipationPancreatic DiseaseNausea / VomitingBarrett’s esophagusCirrhosis / HepatitisGallbladder ProblemsRectal BleedingAnal FissureColon Polyp(s)Difficulty SwallowingOther
Bladder/Kidney*

NoneKidney StonesBlood in UrineProstate ProblemsKidney Failure / Renal InsufficiencyLeaking urine w/ cough/laugh/sneezingMen: PSA test in last year?Trouble starting urineBurning / Pain on urinationUrinary Urgency/FrequencyOverall Loss of Bladder ControlOther
Breast*

NoneCancerPainLumps/Fibrocystic DiseaseAbscessOther
Gynecologic (women only)*

NoneProblems Conceiving / InfertilityCurrently PregnanUterine / Ovarian CancerPOCSMenstrual IrregularityMenstrual PainExcessively Heavy PeriodsPlan to have more childrenPost MenopausalPainCancerOther
Musculoskeletal*

NoneShoulder PainNeck PainElbow PainHip PainWrist PainBack PainFoot PainKnee PainAnkle PainPlantar FasciitisHeel PainBall of Foot PainBroken BonesCarpal Tunnel SyndromeLupusMuscle Pain / SpasmSciaticaRheumatoid ArthritisFibromyalgiaOther
Neurologic*

NoneBalance DisturbanceDizzinessRestless Leg SyndromeStrokeSeizures or convulsionsWeaknessKnocked UnconsciousNumbness / TinglingMultiple SclerosisPseudotumor Cerebri (loss of vision from high pressure in brain)Other
Psychiatric*

NoneAttempted suicideCurrently taking medications for psychiatric problems or for depressionBeen hospitalized for psychiatric problemsBeen in a chemical dependency programSeeing a Psychiatrist or CounselorDepressionAnxietyBipolar DisorderAlcoholism / Substance AbuseVictim of Mental/Emotional/Sexual/Physical AbuseAttention Deficit DisorderOther
Blood/Lymphatic*

NoneLow Platelets (thrombocytopenia)Bruise EasilyBleeding/Clotting DisorderPrior blood TransfusionOther
Low Platelets (thrombocytopenia)*

NoneAnemiaHIV / AIDSLymphomaSwollen Lymph NodesBlood thinning medicine useHistory of DVT / PEOther
Skin*

NoneFrequent Skin InfectionsKeloids (Excessively Raised Scars)Poor Wound HealingPsoriasisRashes under Breasts / Skin FoldsRosaceaHair or Nail ChangesMelanomaCancerOther
Hernia(s)*

NoneUmbilical HerniaVentral HerniaIncisional HerniaGroin HerniaFlank HerniaOther
Chronic pain syndrome*

YesNo
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