Today's Date  ______________   Date you attended educational seminar  _______________

Your Full Name   __________________________________________________________

Birthdate  _______________      Age ________             Sex   Male _____    Female _____

Social Security Number ______________________ (used for billing purposes only)

Street address ____________________________________________________________

City  ____________________________     State  _____________   Zip Code  _________

Home Tel # __________________________  Cell # ______________________________

Occupation ____________________________________  Tel # _____________________

Employer Info ____________________________________________________________

Marital Status      Single _____    Married _____    Widowed _____    Divorced _____

Spouse's Name ______________________________ Birthdate _____________________

List number of children and their ages __________________________________________

Emergency Contact and  Tel. # _______________________________________________



Insurance Information

Have you verified your insurance benefits with your insurance provider? __________________

Insurance Company ____________________  ID# ________________________________

Policy Holder's Name _______________________________________________________

Relationship to Patient _________________ SS# of policy holder _____________________

Insurance Company Telephone # (list all) ________________________________________



Family Physician Information

Name of Doctor ____________________________ Tel # _________________________

How long has this doctor been your medical provider? ______________________________

Date of last physical exam _______________   Date of last blood work ________________

Have you discussed weight loss surgery with your primary care physician ________________



Body Size and Weight History Information

In what year were you at your lowest weight _____________ What was your weight _______

In what year were you at your highest weight _____________ What was your weight _______

Current height _________________     Current weight __________________

Are you currently dieting _________________  if yes, for how long ____________________

Are you enrolled in a supervised exercise program _________________________________



Diet History (complete all that apply)

When did you begin seriously dieting  _______  What was your weight at that time  ________

Atkins Diet         
What Year _______  Pounds lost _____  Re-gained ____

Cabbage Soup Diet          
What Year _______  Pounds lost _____  Re-gained _____

High Protein                    
What Year _______  Pounds lost _____  Re-gained _____

Jenny Craig                      
What Year _______  Pounds lost _____  Re-gained _____

L.A. Weight Loss               
What Year _______  Pounds lost _____  Re-gained _____

Medifast                          
What Year _______  Pounds lost _____  Re-gained _____

Nutrisystem                        
What Year _______  Pounds lost _____  Re-gained _____

Optifast                              
What Year _______  Pounds lost _____  Re-gained _____

O.A.                                   
What Year _______ Pounds lost _____  Re-gained _____

Pritikin Diet                         
What Year _______ Pounds lost _____  Re-gained _____

Richard Simmons               
What Year _______ Pounds lost _____  Re-gained _____

Slim Fast                             
What Year _______ Pounds lost _____  Re-gained _____

South Beach                       
What Year _______ Pounds lost _____  Re-gained _____

T.O.P.S.                            
What Year _______ Pounds lost _____  Re-gained _____

Weight Watchers                
What Year _______  Pounds lost _____  Re-gained _____

Books/Tapes                     
What Year _______  Pounds lost _____  Re-gained _____

Acupuncture                      
What Year _______  Pounds lost _____  Re-gained _____

Hypnosis                            
What Year _______  Pounds lost _____  Re-gained _____

Other ____________________________________________

What Year _______  Pounds lost _____  Re-gained ____



Weight Loss Medications Tried

Fen/Phen
What Year _______   How Long  _______   Dr. Supervised _______  Pounds Lost _______

Liquid Drops
What Year _______   How Long  _______   Dr. Supervised _______  Pounds Lost _______

Meridia
What Year _______   How Long  _______   Dr. Supervised _______  Pounds Lost _______

Xenical 
What Year _______   How Long  _______   Dr. Supervised _______  Pounds Lost _______

Redux
What Year _______   How Long  _______   Dr. Supervised _______  Pounds Lost _______

Over the Counter Pills
What Year _______   How Long  _______   Dr. Supervised _______  Pounds Lost _______

Other
What Year _______   How Long  _______   Dr. Supervised _______  Pounds Lost _______

If you can provide receipts, enrollment forms or records for any of the above, please bring them with you to your first visit with Dr. Patel.



List all Allergies:

________________________________________________________________________

________________________________________________________________________

List all Medications and Dosages:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

List all Serious Illnesses and Surgeries you have Experienced:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Have you or Do you suffer from any of the following:(circle all that apply)

Cardiovascular:

•High Blood Pressure  •Heart Murmur    •Chest Tightness   •High Cholesterol     •Chest Pains   

•High Triglycerides   •Shortness of Breath    •Heart Disease   •Irregular Heartbeat  • Stroke   

•Heart Attack      •CABG   •Problems with leg veins    •Swelling of the legs    •Pain in legs 



Respiratory:

•Wheezing  •Cough/Chest Congestion   •TB   •Emphysema   •Blood Clot in Lungs  •Asthma

•Sleep Apnea - year diagnosed _____________     •Bronchitis    •Use Oxygen    •Snore



Gastrointestinal and Genitourinary:

•Gallstones   •Stomach Ulcers   •Kidney problems     •Blood in Urine     •Painful Urination 

•Rectal Bleeding  •Chron's Disease   •Constipation   •Laxative Use    •IBS    •Diarrhea

•Heartburn   •Nausea and Vomiting   •UTI    •Hiatal Hernia    •Belching up acid or sour fluid



Endocrine:

•Frequent Flushing   •Hypothyroidism   •Hyperthyroidism   •Thyroid Nodules  •Graves Disease

•Adrenal Disease  •Pituitary Disease   •Pre-Diabetic   •Diabetes - last blood sugar _________

•Hypoglycemia   •Gestational Diabetes   •Neuropathy



Musculoskeletal:

•Degenerative Joint Disease   •Back Pain    •Arthritis    •Herniated Discs    •Rheumatism

•Sciatica    •Neck Pain   •Depression from Bra Straps (women only)   •See Chiropractor

•See Orthopedic Surgeon   •Gout   •Use Walker   •Hip Pain   •Knee Pain   •Fluid in Joints



Neurological:

•Numbness/Tingling - where _________________   •Muscle Weakness  •Epilepsy/Seizures

•Severe Headaches   •Loss of Consciousness  •Tremors/Shakiness   •Dizziness/Vertigo

Are you taking any medications for any of the above, if yes what _______________________


Psychological:

•Depression    •Anxiety   •Suicidal Thoughts   •Eating Disorder  •Victim of sexual abuse

•Needed Psychological Counseling   •Victim of Physical Abuse   •Anorexia/Bulimia

•Victim of Verbal Abuse   •Been Hospitalized for Psychiatric Disorder



Hematologic/Dermatologic:

•Sickle Cell Disease   •Bruise Easily   •AIDS/HIV exposure   •Been on Blood Thinners

•Had Blood Transfusion   •Skin Rashes   •Hair Loss   •Yeast or Fungal Infections   •Cancer




Do you smoke __________  if yes, for how long _________ how much _______________

Do you drink   __________  if yes, for how long _________ how much _______________

Do you use recreational drugs: ___________  what kind ___________________________

Do you use prescription pain medications _________  for what ______________________



Thank you for taking the time to complete this packet.  Please return the completed packet to Dr. Patel on your first visit with him.  We will use the information contained in this packet to process your pre-certification request for Lap-Band® with your insurance company.  All information in this packet is subject to HIPAA compliance and will remain at the most strict of confidence.