New Life Patient Medical History
Patient Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Visit
*
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Height
*
Weight
*
***Please Mark all that apply and if Applicable, include the date of occurrence***
ENDOCRINE
Rows
Current
Past
Diabetes Type 1
Diabetes Type 2
Pre-Diabetic/Insulin Resistant
Hypothyroidism
Hyperthyroidism
High Cholesterol
Recent Weight Gain - how many LBS?
Recent Weight Loss - how many LBS?
Fever - how high?
SKIN/ Breast
Rows
Current
Past
Breast Cancer
Skin Cancer
Scleroderma
Breast Lump/mass
Breast Pain
Skin Lesions
Skin Rash
Skin Fold Irritation
ENMT
Rows
Current
Past
Hearing Loss
Bleeding Gums
HEMATOLOGIC/LYMPH
Rows
Current
Past
Blood Clot
Deep Vein Thrombosis
Superficial Blood Clot
Vena Cava Filter Placement
Hemophilia A
Carrier A
Hemophilia B
Carrier B
Iron Deficiency Anemia
Anemia
HIV Infection
AIDS
Leukemia
Non-Hodgkin's Lymphoma
Lymphoma
Easy Bruising
Swollen Lymph Nodes
Location of swollen lymph nodes?
EYES
Rows
Current
Past
Glaucoma
Blindness
Eye Pain
Visual Impairment
Diabetic Retinopathy
GASTROINTESTINAL
Rows
Current
Past
Gallstones
Diverticulosis
Diverticulitis
Irritable Bowel
Crohn's Disease
Ulcerative Colitis
Colon Cancer
Jaundice
Hepatitis B
Hepatitis C
Chronic Liver Disease
Fatty Liver
Cirrhosis
Hiatal Hernia
Internal Hernia
Inguinal Hernia
Location of Inguinal Hernia?
GASTROINTESTINAL
Rows
Current
Past
Umbilical Hernia
Incisional Hernia
Ventral Hernia
Acid Reflux / GERD
Heartburn
Difficulty Swallowing
Black/ Tarry Stool
Nausea
Vomiting
Hepatitis A
Constipation
Diarrhea
GI Infections
Abdominal Pain
Location of abdominal pain?
Date abdominal pain started?
Provider Signature
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
New Life Bariatric Patient Medical History
continued
Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
GENITOURINARY
Rows
Current
Past
Receiving Dialysis
Dialysis start date?
GENITOURINARY
Rows
Current
Past
Chronic Renal Failure
Acute Renal Failure
End Stage Renal Disease
Kidney Stones
Blood in Urine
Pain with Urination
Frequent Voiding
Stress Incontinence
Benign Prostate Hypertrophy
Male Infertility
Polycystic Ovarian Syndrome
Female Infertility
Menorrhagia
Amenorrhea
Irregular Length of Period
Possible Pregnancy
CARDIOVASCULAR
Rows
Current
Past
Chest Pain
Date Chest Pain started?
CARDIOVASCULAR
Rows
Current
Past
Tachycardia
Rhythm Disorder
Murmurs
Pacemaker
Date Pacemaker placed?
CARDIOVASCULAR
Rows
Current
Past
High Blood Pressure
Congestive Heart Failure
Limb Swelling
Location of Limb Swelling?
CARDIOVASCULAR
Rows
Current
Past
Heart Attack
Date of Heart Attack?
CARDIOVASCULAR
Rows
Current
Past
Peripheral Artery Disease
Ischemic Heart Disease
Peripheral Vascular Disease
SLEEP APNEA
Rows
Yes
No
Do you have Sleep Apnea?
Excessive / Loud Snoring?
Daytime Sleepiness
Has someone observed you stop breathing while asleep?
SLEEP APNEA
Rows
CPAP
BiPap
Other
Do you use?
RESPIRATORY
Rows
Current
Past
Cough
Shortness of Breath
Asthma
Bronchitis
Pneumonia
Tuberculosis
Emphysema
Pulmonary Hypertension
Pickwickian Syndrome
Pulmonary Embolism
Date of Pulmonary Embolism?
MUSCULOSKELETAL
Rows
Current
Past
Arthritis
Location of Arthritis?
MUSCULOSKELETAL
Rows
Current
Past
Osteoarthritis
Location of Osteoarthritis?
DIFFICULTY WALKING?
Rows
Walker
Cane
Use of:
MUSCULOSKELETAL
Rows
Current
Past
Lupus
Sclerosis
Upper Back Pain
Lower Back Pain
Sciatica
Leg Pain
Muscle Cramps
Fibromyalgia
Gout
NEUROLOGICAL
Stroke Date?
Aneurysm Date?
NEUROLOGICAL
Rows
Current
Past
Diabetic Neuropathy
Migraine Headaches
Convulsive Disorder
Seizure Disorder
Pseudotumor Cerebri
Confusion
Dizziness
MENTAL HEALTH
Rows
Current
Past
Bipolar Disorder
Anexiety
Personality Disorder
Depression
Provider Signature
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
New Life Bariatric Patient Medical History
Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Last Mammogram?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Last Colonoscopy?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you had a DEXA of Bone Density Scan?
Yes
No
Date?
Social History
Do you drink alcohol?
Yes
No
How often?
SOCIAL HISTORY
Rows
Yes
No
Do you drink Caffeine?
Do you use Illegal Drugs?
Do you Smoke?
Have you ever smoked?
Do you use other Tabacco?
FAMILY HISTORY
Rows
Yes
Relation?
Heart Disease
Hypertension
Diabetes
Stroke
Cancer
Cancer Type and Family Member?
SURGICAL HISTORY
Place the date next to any surgery you have had in the past.
ARTERIAL SURGICAL HISTORY
Rows
DATE
AAA Repair
Previous Coronary Artery ByPass
Stent Placement - Arm or Leg
Temporal Artery Biopsy
ByPass Graft of Extremity
Location of ByPass Graft of Extremity?
CARDIOVASCULAR SURGERIES
Rows
DATE
Heart Valve Replacement
CABG- Heart ByPass
Pacemaker Placement
Cardioverter/ Defibrillator
Cath Stent Placement
Lung Surgery
WEIGHT LOSS SURGERY
Rows
DATE
Roux en Y Gastric By-pass
Distal ByPass
Adjustable Band
Sleeve Gastrectomy
LGCP
BPD with DS
BPD without DS
Revision / Conversion to another procedure
HEAD AND NECK SURGERY
Rows
DATE
Thyroid Surgery
Parathyroid Surgery
Carotid Thromboendartectomy
Tonsillectomy / Adenoidectomy
Cataract Surgery
Craniotomy
FEMALE SURGERY
Rows
DATE
Breast Surgery
Hysterectomy
Oophorectomy
Tubal Ligation
Cesarean Section
URINARY SURGERY
Rows
DATE
Nephrectomy
Lithotripsy
Prostate Surgery
Continent Ureteral Diversion
URINARY SURGERY
Rows
DATE
Nephrectomy
Lithotripsy
Prostate Surgery
Continent Ureteral Diversion
GASTROINTESTINAL SURGERY
Rows
DATE
Appendectomy
Gallbladder Surgery
Partial Colectomy
Colostomy
Ileostomy
Hemorrhoidectomy
Small Bowel Resection
Splenectomy
Pancreatectomy
Ulcer Care
Liver Transplant
HERNIA SURGERY
Rows
Right
Left
Date
Inguinal Hernia Repair (which side?)
Umbilical Hernia Repair
Femoral Hernia Repair (which side?)
Incisional Hernia Repair
Ventral Hernia Repair
Internal Hernia Repair
Hiatal Hernia/ Nissen Fundoplication
MUSCULOSKELETAL SURGERY
Rows
Right
Left
Date
Back Surgery
Total Hip Replacement (which side?)
Knee Replacement (which side?)
Rotator Cuff Repair
Fracture? Location:
Provider Signature
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
New Life Bariatric Patient History
Name
*
First Name
Last Name
Have you had any fall with injury?
Yes
No
If yes, how long ago?
MEDICATIONS
Please list all medications you take, include any occasional or over the counter medications. Please put name, dosage/strength, and frequency of each medication. If you have a copy of your medication list on your computer, please print it and bring it with you.
Medication List
Rows
Name
Dosage/ Strength
Frequency taken
1
2
3
4
5
6
7
8
9
10
11
12
ALLERGIES
Please list allergies you have to any medications and non-medications. Please include the reaction you had.
Allergies List
Rows
Allergy
Medication
Non-Medication
Reaction
1
2
3
4
5
6
7
8
9
10
11
12
Provider Signature
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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