Exit this survey University Bariatrics Application (General Surgery) 1. 100% of survey complete. Thank you for considering our practice. Once you hit DONE at the end of the questionnaire, your application will be submitted to us electronically and in a HIPAA compliant fashion. If you have not heard back from us within 1-2 business days, please contact us at (805) 379-9796. If you prefer, a PDF of this questionnaire can be emailed or mailed to you. Question Title 1. Your full name Question Title 2. Your date of birth? Question Title 3. Mailing address: Question Title 4. Best telephone number(s) to reach you and leave private messages. Question Title 5. Email address(es) where you can receive personal private emails. Question Title 6. Emergency contact information: Question Title 7. What is your insurance? Please include as much information as possible including policy number. Question Title 8. If possible, please upload a copy of your insurance card(s), front and back. Supported formats are PDF, JPG,JPEG,GIF, PNG,DOC,DOCX DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File If possible, please upload a copy of your insurance card(s), front and back. Supported formats are PDF, JPG,JPEG,GIF, PNG,DOC,DOCX Question Title 9. Primary care MD: Please include full name, address, phone and fax, and if known, email address Question Title 10. Please provide the name, specialty, and complete contact information for your other doctors & healthcare providers Question Title 11. How did you hear about University Bariatrics? Doctor referral Friend or family member or coworkers Internet search Social sites such as Facebook, Twitter etc Hospital website or doctor referral line Other Other (please specify) Question Title 12. If you found us through a hospital website, advertising campaign, or doctor referral line: please indicate which one. Los Robles Medical Center (HCA System) St. Johns Regional (Dignity Health System) Simi Valley Hospital (Adventist Health System) Other (please specify): Question Title 13. What is the primary reason you are seeing us? Question Title 14. Cardiac history: Please mark all that apply. High blood pressure (including medication controlled) Heart attack Congestive heart failure Abnormal heart rhythms I have or have had a pacemaker Murmurs Pulmonary hypertension Known abnormal EKGs Swelling of the legs during the day None of the above Other If other (please specify) Question Title 15. Pulmonary History: Please mark all that apply. Known obstructive sleep apnea on CPAP or BiPap Known obstructive sleep apnea but not on CPAP or BiPap Tuberculosis or fungal infections History of pneumonia Emphysema Asthma Shortness of breath on exertion eg going up stairs Lung or other airway cancer None of the above Other: If other (please specify) Question Title Please calculate your sleep score and document in the next question. Score above 9 may indicate sleep apnea. Question Title 16. What was your Epworth Sleepiness Score from chart above? Question Title 17. Gastrointestinal history: Please mark all that apply. Heartburn (gastric reflux disease) Food getting stuck Documented gastroparesis Barretts esophagitis Pernicious anemia Gastric polyps Biliary colic (gallbladder pains) Diarrhea Constipation Irritable bowel syndrome Celiac sprue Lactose intolerance Inflammatory bowel disease (ulcerative colitis or Crohns) Rectal bleeding Colon or small intestine polyps Fatty liver Liver cirrhosis Any gastrointestinal cancer I have had a colonoscopy I have had an upper endoscopy (EGD) None of the above Other: If other (please specify) Question Title 18. Endocrine history: Please mark all that apply. Insulin treated diabetes Oral medication treated diabetes Hyperlipidemia (cholestrol and/other lipids) Hyperthyroidism (overactive) Hypothyroidism (underactive) Endocrine cancers such as thyroid, adrenal, pituitary, etc None of the above Other: If other (please specify) Question Title 19. Hematological history: Please mark all that apply Religious or cultural opposition to blood transfusion even if it means saving one's life Abnormal bleeding (ie do not clot easily) Hemophilia Known clotting disorders (ie hypercoagulable diseases) History of pulmonary embolus IVC filter History of blood transfusion Any form of immunodeficiecy such as HIV Hepatitis A or B or C Leukemia Lymphoma None of the above Other: If other (please specify) Question Title 20. Urinary history: Please mark all that apply Stress urinary incontinence "Suspension surgery" for stress incontinence Benign prostatic hypertrophy Any prostate surgery Frequent urinary tract infections Kidney failure history (now or in past) Dialysis dependent Urological cancers None of the above Other: If other (please specify) Question Title 21. GYN history (women only): Please mark all that apply Menopause Irregular periods/vaginal bleeding not related to menopause Endometriosis Polycystic ovarian disease Infertility Tubal ligation Hysterectomy GYN hormones (eg birth control pills, depo shots) Any GYN cancer None of the above Other: Other (please specify) Question Title 22. Musculoskeletal history: Please mark all that apply Joint pains eg shoulders, knees, hips, feet, etc (indicate below which ones) Back pain related to being overweight Diagnosed with early arthritis Severe arthritis or joint loss requiring orthopedic surgery History of orthopedic surgeries I have been told that my weight prevents me from having necessary orthopedic surgery None of the above Other: Please specify which joints hurt: Question Title 23. Neurological history: Please mark all that apply Stroke or transient ischemic attack Migraines or other severe headaches Pseudotumor cerebri Brain tumors Multiple Sclerosis Myasthenia gravis None of the above Other: Other (please specify) Question Title 24. Psychological history: Please mark all that apply. Depression Anxiety Panic attacks Chronic fatigue syndrome Anorexia/bulemia History of suicide Obsessive compulsive disease (eg wash hands several times) Bipolar disorder Muliple personality disorder Schizophrenia or similar diagnosis None of the above Other: If other (please specify) Question Title 25. Other history: Skin cancers or precancerous lesions Rheumatologic disorders such as RA, Sjogrens, etc Hair loss Psoriasis or Eczema Eye problems HIV or other immunodeficiency None of the above Other: Other (please specify) Question Title 26. Other past medical or surgical history or hospitalizations not mentioned above. Please include approximate dates and write on SEPARATE lines for each event. Question Title 27. If you have had general anesthesia before, i.e. have been put to complete sleep for a surgical procedure, please check the appropriate box. I have never had general anesthesia I have had general anesthesia in the past and had no problems I have had general anesthesia in the past and had problems If had problems, please elaborate: Question Title 28. COMPLETE list of prescription medications. Question Title 29. COMPLETE list of non-prescription, over-the-counter, or herbal medications and supplements. Question Title 30. Drug or other chemical allergies No drug, chemical , or food allergies Food allergies Latex allergy IV dye allergy (eg for CT scans or other xray tests) Allergies to other medications or chemicals Please specify EACH allergy on a SEPARATE line and include what kind of reaction (eg nausea, rash, stop breathing, etc)) Question Title 31. Family history: Please mark all that apply. Obesity Cancer Blood clots and embolism Diabetes Heart disease High blood pressure Hyperlipidemia Strokes Neurological disorders such as Parkinsons, Alzheimers, etc Anesthesia problems Other: Other (please specify) Question Title 32. Current alcohol history: none Less than five drinks per week More than 6 drinks per week Beer Beer none Beer Less than five drinks per week Beer More than 6 drinks per week Wine Wine none Wine Less than five drinks per week Wine More than 6 drinks per week Other liquor Other liquor none Other liquor Less than five drinks per week Other liquor More than 6 drinks per week Question Title 33. Current tobacco/nicotine history: No Yes Cigarettes Cigarettes No Cigarettes Yes Cigar Cigar No Cigar Yes Chewable tobacco Chewable tobacco No Chewable tobacco Yes E-cigarrettes E-cigarrettes No E-cigarrettes Yes Pipe Pipe No Pipe Yes Hookah or other modalities Hookah or other modalities No Hookah or other modalities Yes If past user and have quit: please indicate when Question Title 34. I currently use drugs including medical marijuana. Yes No Question Title 35. What is your current occupation Question Title 36. Marital status Married Single Age of kids if any? Question Title 37. What is your highest education level? Middle school High school diploma or equivalent Technical/vocational school College (2 or 4 year) Graduate school None of the above Question Title 38. This application has been filled out by myself or with the help of someone else under my guidance. In either case, by writing my name below, I attest that all the information is accurate to the best of my abilities. Done