Bariatric Patient Questionnaire

Surgery at Tallgrass Paperwork

Thank you for your interest in our bariatric surgery program. As you may have already discovered, the evaluation for this type of procedure can be quite complex and difficult. These questions are designed to help speed up your evaluation and assist in insurance authorization. Please answer these questions to the best of your ability.

Patient Information:
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Emergency Contact:
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Allergies, Reactions and Habits:
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Do you use tobacco?

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Do you drink alcohol?

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For Women Only:
Are you currently taking birth control?

Medical History - Related to Obesity:
Cardiomyopathy

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Coronary Heart Disease

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Cushing’s Syndrome

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Gastroesophageal Reflux Disease

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Hypertension

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Do you have Osteoarthritis?

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Do you have Diabetes?

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If yes, take Insulin?

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Use the BMI Calculator (Opens in a new window).
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Sleep Apnea
Have you been diagnosed with sleep apnea?

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Use a CPAP

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Sleep Behavior
Snoring

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Insomnia

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Excessively tired during the day

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Wake during the night feeling breathless

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Been told you stop breathing during sleep

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Have a history of hypertension

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Other Medical History:
Arthritis

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Cancer

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Emphysema/Chronic Bronchitis

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Heart Disease

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Heel Spurs

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Kidney Disease

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Low Back Pain

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Obesity Hypoventilation Syndrome

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Plantar Fasciitis

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Polycystic Ovary Syndrome

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Pseudotumor Cerebrii

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Stress Urinary Incontinence

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Check or list any prescription medications taken for weight loss:



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Family Medical History:
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Diet History:
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Interests:
I am interested in: Check all that apply




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How did you hear about us?
 
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