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Weight Loss Clinic Patient Paperwork

You MUST fully complete this document. The information contained within this form will be used to provide the best care for you and to obtain insurance authorization for your procedure.
 
Weight history
6. Weight history by life event
Age Weight
High school graduation
Marriage
Lowest weight in past 5 years
Highest weight in past 5 years
Goal weight
Weight loss surgery history
7. Have you ever had weight loss surgery? If yes, please complete the table below. 
Procedure Date of surgery Location of surgery Surgeon
Surgery 1
Surgery 2
Past weight loss attempts
8. Medications: Have you ever taken any medication for treatment of obesity? If yes, please complete the table below:
Name of med Prescribing doctor How long Weight lost Weight gain Reason for discontinuing
One
Two
Three
Four
Five
9. Past NON-medications weight loss attempts. Examples: Weight Watchers, low carb, Atkins, paleo, your own plan, hypnosis, exercise only, etc.
Type Year How long Weight loss Weight regained
One
Two
Three
Four
Five
Sleep apnea
10. Sleep apnea?
11. Sleep apnea: do you use...
Epworth Sleepiness Scale
DO NOT COMPLETE EPWORTH SLEEPINESS SCALE IF YOU ARE USING A CPAP OR BIPAP FOR SLEEP APNEA
The Epworth Sleepiness Scale is used to measure sleep deprivation. This survey asks for you view about your health. Please carefully read the following questions and write in the most appropriate response. How likely are you to doze off or fall asleep in the situations below, in contract to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work our how they would have affected you.

 
15. Use the following scale to choose the most appropriate number for each situation:

                0 = NEVER doze
                1 = SLIGHT chance of dozing
                2 = MODERATE chance of dozing
                3 = HIGH chance of dozing
Chance of dozing
0: NEVER doze 1: SLIGHT chance of dozing 2: MODERATE chance of dozing 3: HIGH chance of dozing
Sitting and reading
Watching TV
Sitting, inactive in a public place (theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
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