FWLS Combo New Patient Demo, Insurance & History Form

FWLS Combo New Patient Demographics, Insurance & History

This is a lengthy form that tells us a lot of important information about you.. Please set aside at least 20 minutes to fill out the questions below.
Full Name*

First NameMiddle NameLast Name
Nickname or preferred name:
Date of Birth*

MonthDayYear
Social Security #
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone *

Area CodePhone Number
E-mail*
Sex*

MaleFemaleOther
Marital Status
Race
Language
Employment Status*
Employer
Occupation
Do you have a Primary Care or Referring Physician?*

YesNo
Referring Physician's Name? If you don't have a Referring Physician, please list NONE.*
Physician's Phone Number

Area CodePhone Number
Preferred Pharmacy*
Pharmacy Phone Number

Area CodePhone Number
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:

First NameLast Name
Sex

MaleFemale
Language
Emergency Cell Phone:

Area CodePhone Number
Emergency Contact Home Phone:

Area CodePhone Number
Emergency Work Phone:

Area CodePhone Number
Relationship to Patient
Is Contact a Parent / Guardian?

YesNo
If patient is under the age of 18, Emergency Contact should be a Parent or Guardian unless patient is an emanicipated minor.
Insurance Information

Please select whether you have health insurance coverage OR if your Bariatric Surgery will be Self-Pay.
I have health insurance.*

YesNo
I am Self-Pay.*

YesNo
Primary Insurance Information
Company*
Member ID*
Group Number:*
BIN Number:*
It might on a separate prescription card
PCN Number:*
It might on a separate prescription card
Insurance Provider Phone Number

Area CodePhone Number
Subscriber Full Name*

First NameLast Name
Sex

MaleFemale
Date of Birth*

MonthDayYear
Subscriber Information (if differs from patient)
Subscriber SSN:
Relationship to Patient
Subscriber's Employer
Employment Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Secondary Insurance Information
Company
Member ID
Group Number:
BIN Number:
It might on a separate prescription card
PCN Number:
It might on a separate prescription card
Insurance Provider Phone Number

Area CodePhone Number
Subscriber Full Name

First NameLast Name
Sex

MaleFemale
Date of Birth

MonthDayYear
Subscriber Information below (if differs from patient)
Subscriber SSN:
Relationship to Patient
Subscriber's Employer
Employment Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Number

Area CodePhone Number
Cell Number

Area CodePhone Number
I authorize Premier Surgical Associates and Foothills Weight Loss Surgeons to verify my insurance benefits on my behalf. I know that I am ultimately responsible for obtaining and understanding all of my insurance benefits.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Do you have any of the following? Check all that apply.

Living WillDo Not Resuscitate (DNR)Power of Attorney (POA)End of Life DecisionNo Cardio-Pulmonary Resuscitation (CPR)None
Notice of Privacy Practices Acknowledged:

I have been given an opportunity to review, ask questions about and understand Premier Surgical Associates' Notice of Privacy Practices for Protected Health Information. A copy is located on premiersurgical.com and foothillsweightloss.com under Patient Paperwork. A copy is also available at the office.
Patient or Guardian's Signature:*

Clear
Today's Date*

MonthDayYear
Date
Premier Surgical Associates, PLLC PLEASE READ

All charges are due at the time of service. If hospitalization or surgery is indicated, we will file your claim directly to your insurance company. Please remember that most insurance companies do not pay the full amount, and therefore, you are responsible for the balance. If there is a problem paying the balance in full, please let us know and we will be happy to work with you.

Financial Responsibility (to be signed prior to your visit):

I understand and commit to the following:

1. I have recieved a copy of Premier Surgical's financial policies and have read and understand these policies.

2. I will pay my cop-pay, deductible and co-insurance at the time of service.

3. I will provide the most current insurance information and immediately notify Premier Surgical of changes.

4. I surgery is required, all or a portion of my financial financial responsibility must be paid prior to surgery.

5. I will follow my insurance company's requirements for referrals and pre-authorizations and I understand that if I fail to do so, my insurance benefits will be reduced and I will be responsible for all denied balances.

6. I understand that I am responsible for all balances after insurance has paid.

7. If I have no insurance, I have informed Premier Surgical and I am responsible for 100% of all balances.

8. A collection fee of 30% will be added to all my accounts that are turned over to collection agencies.
Patient or Guardian's Signature:*

Clear
Today's Date*

MonthDayYear
Date
Insurance Authorization and Release:

I request that payment of authorized benefits - inclulding Medicare, and any other government sponsored program, private insurance, and any other health plans - be made to Premier Surgical Associates, PLLC, for any services furnished by that provider. I authorize any holder of medical information about me to release to those persons or companies presenting a legitimate request for such information needed to determine these benefits or the benefits payable for related services. I authorize Premier Surgical Associates, PLLC, to act as my agent to help me obtain any required precertification as well as acting as my agent to help me obtain payment from my insurance companies. I authorize my insurance companies to give Premier Surgical Associates, PLLC, any information they require to fulfill this function. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the orginal.
Patient or Guardian's Signature:*

Clear
Today's Date*

MonthDayYear
Date
As of October 16, 2013, the FCC is requiring all businesses (including healthcare companies) to retrieve consent from their customers before enrolling their cell phone in auto-dialing. This includes appointment reminders, which obviously affects us.

By including your cell phone number, you have given Premier Surgical Associates, PLLC, consent to call your cell phone for appointment reminders using our automated system.
Patient or Guardian's Signature:*

Clear
Today's Date*

MonthDayYear
Date
Missed Appointment Policy:

In order to provide the best care and service to our patients, we ask that you notify us 24 hours in advance to cancel and/or reschedule your office visit, ultrasound or other diagnostic test appointment. A minimum of 30 and up to 90 minutes is set aside for each appointment and your communication and compliance is much appreciated by your physician and supporting staff. Please be aware that if 24 hours notice is not recieved a fee of $25 may be charged to your account which must be settled before another appointment is scheduled. Please call us at 865.984.3413 if you are unable to keep your scheduled appointment. This will provide us an opportunity to reschedule your appointment to a more convenient time and avoid any additional charges on your account.
Patient or Guardian's Signature:*

Clear
Today's Date*

MonthDayYear
Date
FOR MEDICARE SUPPLEMENT POLICIES ONLY

One Time Medigap Assignment and Release
Name

First NameLast Name
Medicare Number
Medicare Policy Name
Medigap Policy Number
I request that payment of the authorized Medigap benefits be made on my behalf to Premier Surgical Associates, PLLC, for services furnished to me by them. I authorize any holder of medical information about me to release it to:
Name of Policy
Any information needed to determine these benefits to the benefits payable for related services. This will remain in effect until revoked in writing. A photocopy of this assignment and released is to be considered as valid as the original.
Patient or Guardian's Signature:

Clear
Date

MonthDayYear
Date
Patient Medical History

Please continue and fill out the information below.
Date of Last Mammogram:
Date of Last Colonoscopy:
Date of Cologuard:
Number of falls in the past year
Please indicate the health care providers you see:

Primary CareCardiologistGastroenterologistOther SpecialistOther Bariatric SurgeonOther
Who is your Gastroenterologist?
What is your Gastroenterologist's phone number?
Who is your Cardiologist?
What is your Cardiologist's phone number?
How did you learn about Dr. Colquitt and Foothills Weight Loss Surgeons?

FriendFamilyPatientHospital or Premier Surgical EmployeeGoogleFacebook
Insurance Company - Which one?
Other
Disease and Medical Conditions History

______________________________________________________________
Do you object to having blood products?*

YesNo

Medical Conditions*

	Yes	No	How many years?	Other Information?
Diabetes
Hypertension
Hyperlipidemia (high cholesterol)
Arthritis
Sleep Apnea
Gout
Hypothyroidism (low thyroid)
GERD (acid reflux)
COPD / Emphysema
Asthma
Pulmonary Hypertension
Congestive Heart Failure
Coronary Artery Disease
Heart attack
Varicose Veins
Depression
Anxiety
Bipolar Disease
Stroke or TIA
Skin Fold Rash
Neuropathy
Pseudo Tumor Cerebri
Cancer
Hemorrhoids
Blood clots in legs or lungs
Polycystic Ovarian Syndrome
Other

GERD/reflux questions

______________________________________________________________If you have no reflux symptoms, you can skip this section

Reflux questionnaire (based on previous week)*

	Never	1 day	2 to 3 days	4 to 7 days
1. In the last week, how often did you have a burning feeling behind your breatbone (heartburn)?
2. In the last week, how often did you have stomach contents (liquid or food) move into your throat or mouth (regurgitation)?
3. In the last week, how often did you feel pain in the middle of the upper stomach area?
4. In the last week, how often did you have nausea?
5. In the last week, how often did you have trouble getting a good night's sleep due to heartburn or reflux?
6. In the last week, how often did you take additional medication for heartburn or reflux , other than what your physician told you to take? (such as Tums, Rolaids or Maalox?)

GERD result
GERD-Health Related Quality of Life instrument (GERD-HRQL)

Scale:
- No symptoms = 0
- Symptoms noticeable, but not bothersome = 1
- Symptoms noticeable and bothersome, but not every day = 2
- Symptoms bothersome every day = 3
- Symptoms affect daily activities = 4
- Symptoms are incapacitating, unable to do daily activities = 5

	0	1	2	3	4	5
How bad is your heartburn?
Heartburn when lying down?
Heartburn when standing up?
Heartburn after meals?
Does heartburn change your diet?
Does heartburn wake you from sleep?
Do you have difficulty swallowing?
Do you have pain with swallowing?
Do you have bloating or gassy feelings?
If you take medication, does this affect your daily life?

How satisfied are you with your present GERD condition?

SatisfiedNeutralDissatisfied
Result
Sleep Apnea

______________________________________________________________
Do you snore loudly? Louder than talking or loud enough to be heard through closed doors*

YesNo
Do you often feel tired, fatigued, or sleepy during the daytime?*

YesNo
Has anyone observed you stop breathing during sleep?*

YesNo
Is your neck circumference ( shirt neck size) greater than 16 inches?*

YesNo
Do you use a CPAP or BiPAP machine?*

YesNo
Diabetes

______________________________________________________________
Is your blood sugar under control? (A1c < 7%)?

YesNo
How many different Diabetic medications do you take?
Do you use Insulin?

YesNo
Surgery History

______________________________________________________________
Have you had any previous surgeries?*

YesNo
Have you had more than 1 previous surgeries?*

YesNo

Please list ALL your previous surgeries including dates.

	Surgery	Date	Hospital
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery

Have you had Bariatric Surgery?*

YesNo
If yes, what procedure?
Date of previous Bariatric Surgery?
Previous surgeon?
Hospital?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Surgeon's Phone Number

Area CodePhone Number
Original weight in lbs.
Lowest weight achieved in lbs.
Where there any complications?

YesNo
If yes, please explain.
Allergies

______________________________________________________________
Do you have any known drug allergies?*

YesNo

Please list allergies:

	Allergy	Reaction
Medication
Medication
Medication
Medication
Food Allergies
Food Allergies

Latex allergy?*

YesNo
Iodine allergy?*

YesNo
Prescription Card Information

______________________________________________________________If you do not have a prescription card in hand, please contact your pharmacy for the info below.
ID#*
PCN#*
BIN#*
Group#*
Medications

______________________________________________________________
Are you currently taking any medication?*

YesNo
Are you more than 1 medication currently?*

YesNo

Please list ALL medications you are currently taking.*

	Drug name	Dose (mg, units, etc.)	How often?	Prescribing Physician Name
Prescription Drug (Copy name from bottle)
Prescription Drug
Prescription Drug
Prescription Drug
Prescription Drug
Prescription Drug
Prescription Drug
Prescription Drug
Over the Counter, herbal medication or vitamin name (Copy name from bottle)
Over the Counter
Over the Counter
Over the Counter
Over the Counter
Over the Counter
Over the Counter
Over the Counter

Family History

______________________________________________________________

Family History (check all diseases that apply)*

	Yes	Relationship
Obesity
Diabetes
Cancer
Heart Disease
Hypertension
Stroke
Other

Do you have any family or friends who have had bariatric surgery? If so, who are they and what procedure did they have?
Social History

______________________________________________________________
Smoking or Vaping?*

YesNeverQuit
If you smoke, how many packs a day?
If you quit smoking or vaping, when? How many months/ years ago?
Do you you drink alcohol?*

YesNo
If you drink alcohol, how much per week/month?
Illicit or recreational drug use?*

YesNever
If yes, name of drug and last use.
Social Determinants of Health

Your health is influenced by factors in your daily life - such as where you live, work, and whether you have access to enough food or reliable transportation. These factors are known as Social Determinants of Health. We ask about them to identify any challenges you may face and connect you with helpful resources. This information allows us to support your recovery after surgery and promote your long-term health.
What is your living situation today?*

I have a steady place to liveI have a place to live today, but I am worried about losing it in the futureI do not have a steady place to live
Think about the place you live. Do you have problems with any of the following? CHECK ALL THAT APPLY*

Pests such as bugs, ants, or miceMoldLead paint or pipesLack of heatOven or stove not workingSmoke detectors missing or not workingWater leaksNone of the above
Within the past 12 months, you worried that your food would run out before you got money to buy more.*

Often trueSometimes trueNever true
Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.*

Often trueSometimes trueNever true
In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?*

YesNo
In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?*

YesNoAlready shut off
How often does anyone, including family and friends, insult or talk down to you?*

NeverRarelySometimesFairly oftenFrequently
How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is:*

Very hardSomewhat hardNot hard at all
Limitations / Disabilities

______________________________________________________________
Disabled?*

YesNo
If yes, for how many years?
Cause of disability?
Limitations:
How many hours do you usually sleep out of a 24 hour day?*
What time do you get up?*
What time is your first meal of the day?*
Do you follow any religious or cultural rules that influence what or how you eat?*

YesNo
If yes, please explain.
Weight History

______________________________________________________________
Enter height
Feet
Inches
Weight*
Highest adult weight*
At what age?
Lowest adult weight
At what age?
When did you begin to gain excessive weight and what would you attribute the weight gain to at that time?*
Weight gain in last 6 months? Lbs?
Have you seen a dietitian?

YesNo
If yes, reason for dietitian visit?
Or weight loss in last 6 months? Lbs.?
Ideal weight in lbs.?
How much weight do you expect to lose after surgery?*

Review of Symptoms

	Yes	No
Recent weight gain
Recent weight loss
Fever
Pain in or around eyes
Vision problems
Hearing loss
Bleeding gums
Chest pain or discomfort
Fast heart rate
Chest pain when climbing stairs
Cough
Shortness of breath
Stomach or intestinal
Black or bloody stool
Jaundice
Nausea
Vomiting
Constipation
Diarrhea
Abdominal pain
Heartburn/ reflux
Blood in urine
Urinary frequency
Pain during urination
Leg pain with exercise
Lower leg swelling
Depression
Anxiety
Memory lapses or loss
Breast lump
Skin lesions
Skin rash
Dizziness
Confusion
Easy bleeding
Easy bruising
Swollen glands neck
Groin lymph node swelling
Possible Pregnancy
Planning to become pregnant
Currently breast feeding

On a scale from 1-5, check the number that best describes you or your situation.*

	1-Strongly Disagree	2-Disagree	3-Neither agree or disagree	4-Agree	5-Strongly agree
I have a family and friends that will be a strong support system for me after surgery.
I have researched bariatric surgery and talked with people who have had weight loss surgery.
I will be involved with my follow up care and attendance at bariatric support groups after surgery.
I am highly motivated.
I am quick to learn and can easily follow directions.

Exercise history (be honest!)*

	Type (walking, weights, etc.)	How often (daily, weekly, etc.)	Date of last exercise
Exercise
Exercise
Exercise
Exercise
Exercise

Nutrition Screening Evaluation

______________________________________________________________ Please check any programs, medications, or diets in the list below that you have previously tried to lose weight.

List of Popular Diets *

	Have tried
COMMERCIAL PROGRAMS
Diet Center
Jenny Craig
LA Weight Loss
NutriSystems
Overeaters Anonymous (OA)
Physicians' Weight Loss Center
Take Off Pounds Sensibly (TOPS)
Weight Watchers
PRESCRIPTION DIET MEDICATIONS
Amphetamines
Meridia (Sibtramine)
Phentermine (Fastin/Adipex/Lonamin)
Xenical (Orlistat)
LIQUID DIETS
Carefast
Formula 3
Medifast
New Direction
Opifast
Slimfast
HERBAL & NON-PRESCRIPTION REMEDIES
Alli
Dexatrim
Ephedra (Ma Huang)
Hydroxcut
Metabolife
POPULAR OR FAD DIETS
Blood Type Diet
Body for LIfe
Cabbage Soup Diet
Calorie Counting
Carbohydrates Addicts Diet
Dr. Phil's Ultimate Weight Loss
Eat More, Weigh Less (Dr. Ornish)
eDiets.com
Grapefruit
Hollywood
Low Carb (Atkins)
Low Fat
Mayo Clinic Diet
Protein Powder
Richard Simmons
South Beach
Sugar Busters
The Zone
Volumetrics
THERAPY & OTHER PROGRAMS/DIETS
Acupuncture
Behavior Therapy
Diabetic Diet
Exercise Program
Fasting
Hypnosis
Inpatient psychiatric program
Previous gastric stapling
Psychotherapy
Registered Dietitian

Other (not list above)
Psychiatric History

_____________________________________________________________________ Please list any psychological or psychiatric treatments received in the past.
A. List any psychological medications take by prescription (dates & dosages)*
B. List any talk therapy or counseling you have had (duration & dates)
C. List any benefits that you perceive yourself as receiving and any adversity that you perceive resulted from the above treatments.
Your Personal Statement

Please write about personal downside of being overweight or obese, and why you want to have bariatric surgery. This can be related to health, pain, embarrassment, or other events. The writing provides personal insight into personal barriers and gateways that influence lifestyle change.
Personal statement: *
Form Completed by (print):*
Relationship to patient:
Signature*

Clear
Today's Date*

MonthDayYear
Date
Thank you for taking the time to complete this information. Now, please click SUBMIT to send your form to our Foothills Weight Loss Surgeons office!
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FWLS Combo New Patient Demographics, Insurance & History

Insurance Information

Patient Medical History

Disease and Medical Conditions History

GERD/reflux questions

Sleep Apnea

Diabetes

Surgery History

Allergies

Prescription Card Information

Medications

Family History

Social History

Social Determinants of Health

Limitations / Disabilities

Weight History

Nutrition Screening Evaluation

Psychiatric History

Your Personal Statement