Empower Medical/Mental Packet

  • EMPOWER Medical/Mental Packet

  • Your first visit to our clinic is our educational seminar and requires a minimum of 1.5 hours. Please arrive 15 minutes early.

    You must submit your completed packet prior to scheduling your first individual appointment.

    Enclosed in this packet is a personal medical history form and a bariatric questionnaire, which must be completed in full. Please mail, email or deliver in-person prior to your first consultation. It is very important that you arrive on time for your scheduled office visits. If you are late, it may be necessary to reschedule.

    You are unable to keep your appointment, please call and notify us at least 24 hours in advance. This will allow us to reschedule with another patient.

    Thank you again for choosing Empower Surgical & Medical Weight Loss as you take this step toward improving your health.

  • PATIENT HEALTH HISTORY QUESTIONNAIRE

  • The following information is very important to your health. Please take time to fully and completely fill out this questionnaire. If there is not room for a complete history, please use additional paper.

  • Format: (000) 000-0000.

  • Please list any specialty physicians you have seen in the past or are currently seeing if it relates to the issue, along with their addresses and phone numbers.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Rows
  • Rows
  • Rows
  • Do you take ibuprofen/NSAIDs or other anti-inflammatory medications?*

  • Past Medical History

  • Rows
  • Rows

  • Have you had the following?

  • Diabetes:*
  • High Blood Pressure:*
  • High Cholesterol:*
  • GERD (reflux/heartburn):*
  • Obstructive Sleep Apnea:*
  • Stress Incontinence:*
  • Lower Extremity Edema:*
  • Polycystic Ovarian Syndrome:*
  • Depression:*
  • Seizures, Stroke, Paralysis:*
  • Ulcers (stomach/intestinal)*
  • Kidney or Bladder Disease:*
  • Liver Disease:*
  • Asthma, Emphysema, Tuberculosis, etc*
  • Arthritis:*
  • Bleeding Problems:*
  • Cancer:*
  • Infectious Disease:*
  • Dialysis:*
  • Eating Disorder:*
  • Heart Disease:*
  • Non Healing Wound:*
  • Venous Statis:*
  • COPD:*
  • Autoimmune Disease:*

  • Weight History

  • Have you ever tried to "go on a diet" to lose weight?*
  • How many attempts have been made to lose weight?*
  • At what age did you first have weight problems?*
  • Have you ever had weight loss surgery before?*
  • What was the date of your surgery?
     / /

  • Family History

  • Have there been any of the following diseases in your family? Please indicate if any family members died

  • Bleeding Disorders:*
  • Diabetes:*
  • Family History of Obesity:*
  • Stroke or Paralysis:*
  • High Blood Pressure:*
  • Family history of Anesthesia Complications?*
  • Cancer:*
  • Lung Disease:*

  • For Female Patients Only:

  • Date of last PAP/Pelvic Exam
     / /
  • Normal?:
  • Date of last breast exam
     / /
  • Normal?:
  • Have you ever had a miscarriage?:
  • Do you plan to have more children?:

  • Social History

  • Status*
  • Do you have children?*
  • Format: (000) 000-0000.
  • Have you ever smoked?*
  • Other nicotine use?
  • Do you drink alcohol?*
  • Have you ever used recreational drugs?*

  • Initial History and Review of Symptoms

  • Constitutional*
  • Respiratory*
  • Hematologic/Lymphatic*
  • Neurological*
  • Eyes*
  • Cardiovascular*
  • Genitourinary*
  • Musculoskeletal*
  • ENT, Mouth, Face*
  • Gastrointestinal*
  • Integument/Breast*
  • Behavioral/Psych*
  • Endocrine*
  • Allergy/Immunology*

  • CPAP Use

  • Do you use a CPAP BiPap, or supplemental oxygen? If no, please complete the Stop-Bang Sleep Apnea Questionnaire below. We can assist you at your first appointment if necessary.*

  • STOP-BANG SLEEP APNEA QUESTIONNAIRE
    (If you marked no to the question above please fill out this questionnaire)

  • Do you SNORE loudly? (louder than talking or loud enough to be heard through closed doors?
  • Do you often feel TIRED, fatigued, or sleepy during the daytime?
  • Has anyone OBSERVED you stop breathing during your sleep?
  • Do you have or are you being treated for high blood PRESSURE
  • Is your BMI more than 35kg/m^2?
  • Is your AGE over 50 years old?
  • Is your neck circumference > 16 inches (40cm)?
  • Is your gender male?

  • Bariatric Surgery Program Pledge

    Please read and check each item

  • DATE*
     / /
  • DATE
     / /
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