DPS-2065-965

12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Packet Checklist
Date Received __________________
o Patient Registration Form – Signed
o Copies of front and back of insurance card
o Dietary History
o Patient Medical Questionnaire
o Letter or medical records from PCP or date to be done __________________
o 5 year weight history
o TSH or date to be done __________________
o Latex Allergy Questionnaire
o Sleep Assessment Tool
o Psychological evaluation or date to be done __________________
o Date seminar attended or scheduled to attend on __________________
DPS-2065-965 (8/2009)
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Thank you for your interest in the weight-loss programs offered at the SSM Weight-Loss Institute. Inside this
brochure you will find information on the weight-loss options we offer. To pursue either option, surgical or
non-surgical, we recommend attending free educational seminars. Dates for surgical seminars and nonsurgical orientations can be obtained on-line. Additionally, for your convenience, the surgical seminar is now
available online at SSMWEIGHTLOSS.com
If you are interested in pursuing weight-loss surgery the paperwork needed to begin the process along
with a self addressed stamped envelope to return is included. It is strongly recommended that you call
your insurance company and inquire about your benefits, the criteria, and pre-authorization for the surgical
treatment of morbid obesity. When inquiring about your benefits your insurance company may request a
procedural code, commonly referred to as a CPT code. The CPT code for gastric bypass is 43644, and
for adjustable gastric banding is 43770. Please note that not all health insurance policies cover surgery for
obesity.
In order to assist you in completing the paperwork included please see a brief explanation and requested
timeline for completion. Your timely completion of these items will expedite the process to obtaining your
surgical approval.
Packet Checklist: As you complete the items required please check appropriate items and return the
checklist with your packet. If you have upcoming appointments with your primary care physician or
psychologist please indicate date and time.
Patient Registration Form: Please complete including primary and secondary insurance information
if applicable and sign at the bottom. Please include copies of your insurance cards front and back
Recommended timeline for completion: 1 week
Dietary History: To be completed by you the patient, as accurate as you can, recalling as many diet attempts
as possible. Please sign at the bottom of the last page. Recommended timeline for completion: 1 week
Patient Medical Questionnaire: Mark appropriate choice of surgical tool at the top of the page along with
requested surgeon. Fill out entire form as completely as you can. Recommended timeline for completion: 1
week
Allergy Recognition Self-Test: Please complete and sign at the bottom of the page. Recommended
timeline for completion: 1 week
Sleep Assessment Tool: Please answer questions directly on the form provided. Recommended timeline
for completion: 1 week
Primary Care Physician Request Form: This form is to be utilized as a tool for your primary care physician
on what the Weight-Loss Institute will need to support your request for weight-loss surgery. Please take it
with you to your appointment so he/she knows what information is needed. Recommended timeline for
completion: 2 weeks
DPS-2065-951 (8/2009) PAGE 1 OF 2
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Mental Health Provider Worksheet: A mental health evaluation is required by our program and your
insurance carrier for weight-loss surgery. This is a list of providers who the Weight-Loss Institute has worked
with previously. These providers are familiar with the needs of a patient seeking weight-loss surgery. Patients
are not required to use anyone on this sheet. Recommended timeline for completion: 3-5 weeks (complete
paperwork promptly, but allow extended time to get an appointment as mental health evaluations often book
quickly)
Dear Doctor Letter: This letter is to be used as a tool for patients seeking weight-loss surgery mental health
evaluations, with a provider that may not have performed this type of evaluation previously. It indicates what is
required to be provided to the Weight-Loss Institute in the form of a report.
Mental Health Provider Facesheet, Background Information and Fees for Service and Payment: In order
to book a mental health evaluation you must complete and return this paperwork to the Weight-Loss Institute.
Once received by WLI staff you will be contacted and scheduled for the next available appointment. You can
fax this paperwork to the attention of Mental Health at 314-344-6801.
Once you have completed your paperwork you can email or mail it back to our office at:
Weight Loss Institute
12266 DePaul Drive
Suite 310
St. Louis MO 63044
Your primary doctor and mental health provider may choose to send their reports to us directly and can do so
by faxing them to 314-344-6801 Att: Pre-Op Staff.
More information on the process can be obtained by attending an educational seminar or online at
SSMWEIGHTLOSS.com. We look forward to working with you in the future and joining you on your journey to
a healthier life!
J. Stephen Scott, M.D., Medical Director, SSM Weight Loss Institute St. Louis
Roger A. de la Torre, M.D., Medical Director, SSM DePaul Weight Loss Institute
DPS-2065-951 (8/2009) PAGE 2 OF 2
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT REGISTRATION
PATIENT INFORMATION
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
LAST NAME ______________________________________________________ FIRST NAME & INITIAL _____________________________________
ADDRESS ________________________________________________________________________________________________________________
CITY _______________________________________________ STATE _____________ ZIP ___________________ PAGER ____________________
HOME PHONE ____________________________ CELL PHONE ____________________________ E-MAIL ___________________________________
DATE OF BIRTH ______________________ SEX: ® M ® F AGE: _______ MARITAL STATUS: ® Married ® Single RACE: _____________________
REFERRING PHYSICIAN __________________________________________ PRIMARY PHYSICIAN _________________________________________
SPOUSE’S NAME ________________________________ SPOUSE’S DOB ________________ SPOUSE’S WORK PHONE_______________________
NEAREST RELATIVE OR FRIEND NOT LIVING WITH YOU _____________________ RELATIVE/FRIEND PHONE ______________ RELATIONSHIP _______
PATIENT SOCIAL SECURITY # ______________________ SPOUSE’S SOCIAL SECURITY # ______________________ SPOUSE DOB______________
PATIENT EMPLOYER ________________________________________________________________________________________________________
EMPLOYER ADDRESS_______________________________________________________________________________________________________
CITY _______________________________________________ STATE _____________ ZIP _______________________
EMPLOYER PHONE _________________________________ EXT. ______________________
GUARANTOR
RESPONSIBLE PARTY LAST NAME ____________________________ FIRST NAME & INITIAL ______________________ RELATIONSHIP____________
ADDRESS ________________________________________________________________________________________________________________
CITY _______________________________________________ STATE _____________ ZIP _______________________
PHONE _________________________________ RESPONSIBLE PARTY SOCIAL SECURITY # ___________________________ DOB______________
RESPONSIBLE PARTY EMPLOYER______________________________________________________________________________________________
EMPLOYER ADDRESS ____________________________________________________ EMPLOYER PHONE ___________________________________
INSURANCE INFORMATION
1. MEDICARE OR INSURANCE #1 NAME _______________________________________________________________________________________
MEDICARE OR INSURANCE #1 ADDRESS ________________________________________ MED. OR INS. #1 PHONE ______________________
POLICYHOLDER LAST NAME ___________________________________ FIRST NAME __________________________ RELATIONSHIP__________
CERTIFICATE NO. ______________________________ GROUP NO. __________________________ MEMBER NO. ________________________
2. MEDICARE OR INSURANCE #2 NAME _______________________________________________________________________________________
MEDICARE OR INSURANCE #2 ADDRESS ________________________________________ MED. OR INS. #2 PHONE ______________________
POLICYHOLDER LAST NAME ___________________________________ FIRST NAME __________________________ RELATIONSHIP__________
CERTIFICATE NO. ______________________________ GROUP NO. __________________________ MEMBER NO. ________________________
I request payment of authorized Medicare, Medigap or any other insurance benefits be made on my behalf to DePaul Weight Loss Institute for any services furnished
to me by that provider. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents or to other
insurers any information needed to determine benefits payable for services from the provider. I hereby authorize the Physician to release any information acquired in
the course of my treatment necessary to process insurance claims.
FINANCIAL LIABILITY: I understand I am fully responsible for all Physician charges. If I have insurance that will cover a portion of my bill, I agree to pay the patient’s
portion of the bill and understand I may be required to make a deposit toward the amount and the balance. The fact I may be covered by insurance does not relieve
my personal obligations to pay all charges. I agree to assure payment of all charges by DePaul Weight Loss Institute.
All of the above information I have given is to the best of my knowledge correct.
SIGNATURE ____________________________________________________________ DATE ________________________
PATIENT LABEL
PATIENT REGISTRATION
DPM-2065-014 (4/2009)
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
DIETARY HISTORY
Patient Name: ________________________________________ Current Weight: ______________ Height: ______________
THIS FORM WILL BE FORWARDED TO YOUR INSURANCE COMPANY AS PART OF THE PREDETERMINED
PROCESS. PLEASE BE AS SPECIFIC AS POSSIBLE. PLEASE CHECK AND ANSWER ALL OF THE FOLLOWING.
M.D. SUPERVISED
DIET PROGRAM
# OF ATTEMPTS
WHEN
LENGTH OF TIME
WEIGHT LOSS WEIGHT GAINED TIME FRAME
Medi-Fast
MD Name &
Address
Opti-Fast
MD Name &
Address
Shots:
H.C.G.
B-6
B-12
MD Name &
Address
Pills:
Ionomine
Amphetamines
Lasix
Redux
Phen-Fen
Meridia
Xenical
MD Name &
Address
Others
ORGANIZED DIET PLANS
DIET PROGRAM
# OF ATTEMPTS
WHEN
LENGTH OF TIME
WEIGHT LOSS WEIGHT GAINED TIME FRAME
Diet Center
Jenny Craig
Nutri Systems
Overeaters Anonymous
TOPS
Weight Watchers
Other
PATIENT LABEL
DIETARY HISTORY
DPM-2065-013 (4/2009) PAGE 1 OF 3
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
DIETARY HISTORY
LIQUID DIETS
DIET PROGRAM
# OF ATTEMPTS
WHEN
LENGTH OF TIME
WEIGHT LOSS WEIGHT GAINED TIME FRAME
Liquid Protein
Metracel
Slim Fast
Other
MISCELLANEOUS DIETS
DIET PROGRAM
# OF ATTEMPTS
WHEN
LENGTH OF TIME
WEIGHT LOSS WEIGHT GAINED TIME FRAME
Atkins
Air Force Diet
Cabbage Soup Diet
Grapefruit
Herbal
High Protein
Low Calorie
Low Fat
Magazine/Book
Self-imposed fast
Other
OVER-THE-COUNTER DIET PILLS
DIET PROGRAM
# OF ATTEMPTS
WHEN
LENGTH OF TIME
WEIGHT LOSS WEIGHT GAINED TIME FRAME
Accutrim
Dexatrim
Diuarex
Other
OTHER TYPES OF WEIGHT LOSS
DIET PROGRAM
# OF ATTEMPTS
WHEN
LENGTH OF TIME
WEIGHT LOSS WEIGHT GAINED TIME FRAME
Hypnosis
Acupuncture
Psychotherapy
Subliminal Tapes
Previous Bariatric Surgery
Other
EXERCISE
DIET PROGRAM
# OF ATTEMPTS
WHEN
LENGTH OF TIME
WEIGHT LOSS WEIGHT GAINED TIME FRAME
Exercise Videos
Fitness Centers
Home Equipment
PATIENT LABEL
DIETARY HISTORY
DPM-2065-013 (4/2009) PAGE 2 OF 3
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
DIETARY HISTORY
EATING DISORDERS
DIET PROGRAM
# OF ATTEMPTS
WHEN
LENGTH OF TIME
WEIGHT LOSS WEIGHT GAINED TIME FRAME
Anorexia
Bulimia
Compulsive Overeater
At what age did you begin your first diet? ________ years
What was your greatest single weight loss? ________ lbs
How long did you sustain that weight loss? ____________________
How was that weight loss obtained? ______________________________________________________
How many times have you lost over 25 lbs? ___________________________________
How long have you been over weight? ________ years ________ months
How long have you been at your current weight? ________ years ________ months
Are you currently under a physician’s care for weight loss? Yes ____ No ____
If yes, please fill in your physician name, address and phone number.
Physician Name:_______________________________________________________
Address: ______________________________________________________________
Phone #: _____________________________________________________________
Patient Signature: _____________________________________ Date: __________________
PATIENT LABEL
DIETARY HISTORY
DPM-2065-013 (4/2009) PAGE 3 OF 3
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Which procedure are you interested in? (Must check one)
Laparoscopic Roux en y Divided Gastric Bypass ______ Adjustable Gastric Banding ______
What surgeon do you wish to see for your operative procedure? (you must check one)
® Dr. Roger de la Torre ® Dr. J. Stephen Scott
GENERAL INFORMATION
________________________________________
LAST NAME
_____________________
DATE OF BIRTH
__________________
HEIGHT
________
AGE
_____________________________
FIRST
____________________
GENDER
__________________
WEIGHT
_________________________________
HOW LONG AT CURRENT WEIGHT
RACE:
Caucasian
African American
Asian
Native American
Hispanic
Pacific Islander
Other____________________________
_________________________________
OCCUPATION
MARITAL STATUS: M S W D
PRIMARY HEALTH CARE PROVIDER
NAME: __________________________________________________________________________________________
ADDRESS: ______________________________________________________________________________________
CITY: _________________________________________ STATE: _______________ ZIP: ______________________
PHONE:_________________________________________________________________________________________
How long has he/she provided medical care for you? _____________________________________________________
OTHER HEALTH CARE PROVIDER(S), INCLUDING SPECIALISTS
NAME: __________________________________________________________________________________________
ADDRESS: ______________________________________________________________________________________
CITY: _________________________________________ STATE: _______________ ZIP: ______________________
PHONE: __________________________________ SPECIALTY: ___________________________________________
NAME: __________________________________________________________________________________________
ADDRESS: ______________________________________________________________________________________
CITY: _________________________________________ STATE: _______________ ZIP: ______________________
PHONE: __________________________________ SPECIALTY: ___________________________________________
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 1 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
PAST MEDICAL HISTORY
WHAT MEDICAL PROBLEMS ARE CURRENTLY BEING TREATED?
Illness
Date
Treatment
Outcome
Treatment
Outcome
PLEASE LIST ANY OTHER MAJOR PAST ILLNESSES
Illness
Date
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 2 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
CURRENT MEDICATIONS
INCLUDING VITAMINS, OVER-THE-COUNTER MEDICATION, AND INTERMITTENTLY USED DRUGS.
(Please list prescription medication first)
Name
Strength
Frequency
Purpose
When Started
ALLERGIES
LIST ALL DRUG ALLERGIES:
Drug Name
Reaction
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 3 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
PAST SURGICAL HISTORY
LIST ANY SURGERIES:
Surgery
Date
Reason
Physician
REVIEW OF SYMPTOMS
General:
Do you suffer from frequent or severe fatigue?
Have you had a recent change in your appetite?
Do you have any frequent or severe weakness?
Have you had any significant weight loss or gain in the last 6 months?
If yes, how much? _____________________________________
Cardiac:
Have you ever had a heart attack?
If yes, when ____________________
Do you get chest pain with activity?
Have you ever had congestive heart failure?
Have you ever undergone a heart stress test?
If yes, when ____________________
Have you ever had a cardiac catheterization?
If yes, when ____________________
Have there ever had any heart rhythm abnormalities?
Have you ever had Rheumatic Fever?
Have you ever been told you have a heart murmur?
Have you ever been told you have coronary atherosclerotic disease?
Y
Y
Y
Y
N
N
N
N
Y
N
Y
Y
Y
N
N
N
Y
N
Y
Y
Y
Y
N
N
N
N
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 4 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Pulmonary:
Do you experience shortness of breath with physical activity?
Y
N
When walking up stairs, how many steps can you climb before noticing shortness of breath?
______ Steps/Flights (Circle one and enter number)
When do you have to stop and rest _______ Steps/Flights (Circle one and enter number)
Do you have asthma?
Y
N
If yes, how long: _____________________
Do you have COPD or emphysema?
Y
N
Do you smoke? Y N
Number of packs _____________________
Number of years _____________________
Do you have sleep apnea?
Y
N
If yes, how long: _____________________
Are you on CPAP/Bi-Pap?
Y
N
Do you use oxygen at home?
Y
N
Do you snore?
Y
N
Do you ever stop breathing while asleep?
Y
N
Do you doze off while talking to someone?
Y
N
Hepatic:
Have you ever had hepatitis?
If yes what type? _____________________________________
Have you been told you have cirrhosis of the liver?
Have you ever been told you have a fatty liver disease?
How much alcohol do you drink? ___________________________
Have you ever had problems with alcohol?
If yes, when: _____________________
Renal:
Are you on Dialysis?
Have you ever had any kidney problems?
If yes, when: _____________________
Have you seen a specialist for kidney problems?
Name of specialist: ______________________________________
Address: ______________________________________________
Phone Number: ______________________________
Y
N
Y
Y
N
N
Y
N
Y
Y
N
N
Y
N
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 5 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Neurological:
Have you ever had a stroke?
Y
N
Do you have Multiple Sclerosis, Parkinson’s disease, or any other neurological disease?
Y
N
If so, what disease? ___________________________________
Do you have Pseudotumor Cerebri?
Y
N
Do you use a wheelchair OR cane? (Please circle)
Do you have frequent or severe headaches?
Y
N
Gastrointestinal:
Do you have Acid Reflux?
Have you ever had: Gallstones
Hiatal Hernia
Diarrhea
Hernia
Blood in stool
Hemorrhoids
Ulcer Disease (Please circle all that apply)
Do you have heart burn?
Are you being treated for acid reflux?
Have you ever had surgery for the treatment of reflux disease?
Endocrine:
Do you have thyroid disease?
Circle which type you have: Hyper (high)
Hypo (Low)
Are you diabetic or insulin resistant or do you have metabolic syndrome
How long have you been diagnosed? ______________________
Are you on insulin? ______________________
Are you on oral medication? ______________________
Do you monitor your glucose?
If yes, how often? ______________________
When was your last Hemoglobin A1C? ______________________
What were the last test results? ______________________
Do you have high cholesterol or high lipids?
Are you treating your high cholesterol?
Y
N
Y
Y
Y
N
N
N
Y
N
(circle one)
Y
N
Y
Y
N
N
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 6 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
BONE OR JOINT PROBLEMS
Do you have any of the following problems:
Location
Swelling
Pain
Stiffness
Popping/Cracking
Ankles
Knees
Hips
Back
Other:
Have you ever sought treatment for bone or joint problems or injuries? Give details (include Physical Therapy and
Chiropractic)
Doctor
Date of Treatment
Diagnosis/Treatment
Have you consulted a Chiropractor?
Y
N
Have you taken any medications for this problem?
Y
N
If yes, what ___________________________________________________________________________
_____________________________________________________________________________________
Have you ever been told you have degenerative joint changes,
or early arthritic changes in your joints?
Y
N
Have you been told you have arthritis?
Y
N
Is your arthritis being treated?
Y
N
Any family history of arthritis or back problems?
Y
N
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 7 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Psychiatric:
Current Psychiatric treatment?
Y
N
Treated by: Psychiatrist Therapist
Current Hospitalization (last 6 months):
Y
N
Treated by: Psychologist Physician
Have you ever been diagnosed with an eating disorder?
Y
N
Past Treatment:
Were you ever hospitalized for Psychiatric treatment?
Y
N
When was your treatment?__________________________________________________________________
Where was your treatment? _________________________________________________________________
What was your treatment for? _______________________________________________________________
Who treated you? _________________________________________________________________________
What medications were you prescribed? _______________________________________________________
________________________________________________________________________________________
Current Treatment:
Who’s care are you under?__________________________________________________________________
Current medications and dosages: ____________________________________________________________
Current diagnosis and reason for treatment? ____________________________________________________
________________________________________________________________________________________
Lifestyle:
Are you currently married?
Y
N
If yes, how long? ____________________
Is this your first marriage?
Y
N
If no, how many previous marriages? ____________
On a scale of 1 to 5 (1 = least happy), how happy are you in your present marriage?
1
2
3
4
5
(circle one)
Are you currently employed? _______________________
If yes, how long have you been employed? ____________________________________
On a scale of 1 to 5 (1 = least happy), how happy are you in your present job?
1
2
3
4
5
(circle one)
On a scale of 1 to 5 (1 = least happy), how would you rate overall satisfaction with yourself?
1
2
3
4
5
(circle one)
Vascular:
Do you have hypertension?
Have you ever had a blood clot?
If yes, when _________________________________
What for of treatment _________________________________
Y
Y
N
N
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 8 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
Vascular, cont’d:
Have you ever had a Pulmonary Embolus?
Do you have a family history of Pulmonary Embolisms or DVT?
If yes, where was your treatment? _________________________
Do you get significant swelling in your legs?
Have you ever had leg ulcers?
Have you ever been treated for cellulites of the lower extremities?
Have you ever been told you have peripheral vascular disease?
Do you have any history of abnormal bleeding?
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Y
Y
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
Urinary:
Do you ever involuntarily lose your urine?
Y
N
If yes, what causes you to lose your urine? Coughing Jumping Sneezing Walking Bending forward
Do you experience pain when urinating?
Y
N
Do you wear pads for protection?
Y
N
How often do you wet your clothing? __________________________
Any history of bladder surgery?
Y
N
If yes, when? ___________________
Reproductive:
At what age did your periods start? _____________________
Have you gone through menopause?
If yes, at what age? _____________________
Are your periods: Regular Irregular
What was the date of your last menstrual period? ___________
Did you experience any cramping?
Have you ever been pregnant?
If yes how many children _____________________
What form of birth control do you use? ________________________
Skin:
Do you suffer from any skin diseases?
If yes, what? ___________________________________
Do you get frequent rashes?
If yes, where? __________________________________
Infection:
Have you suffered frequent infections?
If yes, what type? _______________________________
Do you have HIV or AIDS?
If yes, when were you diagnosed? _______________________
Y
N
Y
Y
N
N
Y
N
Y
N
Y
N
Y
N
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 9 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PATIENT MEDICAL QUESTIONNAIRE
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
FAMILY HISTORY (Grandparents, Parents, Siblings)
✓ CHECK ALL THAT APPLY
Family Member
Age
now or
at death
Cause of death
Thin
Normal
Weight
Slightly Moderately
Quite
overweight overweight overweight
Health Problems
What other family members are obese (indicate mother’s/father’s side of your family)?
________________________________________________________________________________________________
________________________________________________________________________________________________
What other family members have or have had:
Breast, colon or prostrate cancer? ____________________________________________________________________
________________________________________________________________________________________________
Cancer (specify type): ______________________________________________________________________________
________________________________________________________________________________________________
Diabetes: ________________________________________________________________________________________
________________________________________________________________________________________________
Heart attack: _____________________________________________________________________________________
________________________________________________________________________________________________
Stroke: __________________________________________________________________________________________
________________________________________________________________________________________________
High blood pressure: _______________________________________________________________________________
________________________________________________________________________________________________
PATIENT LABEL
PATIENT MEDICAL QUESTIONNAIRE
DPM-2065-002 (8/2009) PAGE 10 OF 10
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PRIMARY CARE PHYSICIAN REQUEST FORM
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Dear SSM Weight Loss Institute,
I am referring my patient ___________________________________________, date of birth ___________________,
to you for your opinion regarding the possibility of weight loss options, including surgery. The patient’s
current weight is: ________, height is: _________, BMI is: ___________. The patient has been morbidly obese
for _______ years.
The patients five (5) year weight history:
(1) Yr: _______ Wt: _______
(2) Yr: _______ Wt: _______
(4) Yr: _______ Wt: _______
(4) Yr: _______ Wt: _______
(3) Yr: _______ Wt: _______
The patient suffers from the following co-morbid conditions associated with morbid obesity which include
(Please check all that apply)
o
o
o
o
o
o
Type 2 diabetes – controlled by oral medications
Type 2 diabetes – controlled by injectable medications
Obstructive sleep apnea
Coronary artery disease
Valvular heart disease
Hypertension
o
o
o
o
o
o
Dyslipidemia
Stress incontinence
GERD
Heart burn
Arthritis
History of medical non-compliance
The patient also has the following conditions that are associated with morbid obesity:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
The patient’s previous weight loss attempts:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
TSH Required. Other tests listed optional, please provide results if applicable.
o Laboratory testing such as lipid panel, HGB A1C, TSH (Required)
o Pulmonary function test
o Sleep Study
o Venous duplex
o Exercise stress test
o Other: ___________________________
This patient has attempted other weight reduction alternatives and has been unsuccessful in maintaining
adequate weight loss. Please render your opinion on appropriate management options.
Sincerely,
_______________________________________
Signature (Required)
________________
Date
(_____)_____________
Phone
_____________________________________
Printed Name
__________________________________________________
__________________________________________________
__________________________________________________
Address (Required)
DPS-2065-975 (8/2009)
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
ALLERGY RECOGNITION SELF-TEST
Are You Allergic to Latex?
Please circle the most appropriate answer and return with your packet.
1.
2.
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13.
Have you ever had allergies, asthma, hay fever, eczema, or problems with rashes?
Yes
No
Have you ever had anaphylaxis or an unexplained reaction during a medical procedure?
Yes
No
Have you ever had swelling, itching, or hives on your lips or around your mouth after blowing up a balloon?
Yes
No
Have you ever had swelling, itching, or hives on your lips or around your mouth after a dental examination
or procedure?
Yes
No
Have you ever had swelling, itching, or hives following a vaginal or rectal examination or after contact with
a diaphragm or condom?
Yes
No
Have you ever had swelling, itching, or hives on your hands during or within one hour after wearing rubber
gloves?
Yes
No
Have you ever had a rash on your hands that lasted longer than one week?
Yes
No
Have you ever had swelling, itching, or hives after being examined by someone wearing rubber or latex
gloves?
Yes
No
Have you ever had swelling, itching, hives, runny nose, eye irritation, wheezing, or asthma after contact
with any latex or rubber products?
Yes
No
Has a physician ever told you that you have a rubber or latex allergy?
Yes
No
Are you allergic to bananas, avocados, kiwi, peaches, potatoes, papaya, or chestnuts?
Yes
No
Are you presently on beta-blockers?
Yes
No
Have you ever had a reaction to any of the following sources of latex?
(Please circle any items to indicate a “Yes” response.)
Rubber Ball
Teething Rings
Latex Blood Pressure Cuffs
Rubber Bands
Erasers
Weather Stripping
Bandages
Corsets
Ostomy Bags
Ace Bandage
Dental Cofferdams
Dental Masks
Brassieres (Bras)
Garden Hoses
Hot Water Bottles
Carpet Backing
Face Masks
Shoewear
Belts
Foam Pillows
Tennis Grip
Rubber Cement
Pacifiers
Adhesive Tape
Suspenders
Golf Grips
IV Tubing
Patient Signature: _________________________________________ Date: ___________________
PATIENT LABEL
ALLERGY RECOGNITION SELF-TEST
DPM-2065-005 (4/2009)
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
SLEEP STUDY QUESTIONNAIRE
o Do you have sleepiness during the day?
o Do you snore while sleeping?
o Do you awaken with a headache every morning?
o Do you routinely have a dry mouth in the morning?
o Do you awaken from sleep gasping or choking?
o you routinely find it difficult to stay awake watching TV, reading a book or attending
oD
a lecture?
o Has anyone told you that you hold your breath, snort and often move while sleeping?
o Do you ever experience muscle weakness when excited or emotional?
o Do you have difficulty falling asleep?
o Do you have difficulty maintaining sleep?
If you checked more than one of these questions, the Weight-Loss Institute may further
evaluate you through our SSM DePaul Sleep Diagnostic Center.
Why should I consider a sleep study?
The National Commission on Sleep Disorders Research found that 40 million Americans are
chronically ill with various sleep disorders. If not treated a sleep disorder could lead to:
• Heart Attacks
• Strokes
• Car Accidents
• Problems at home or work
Most sleep disorders are easily treated and can greatly improve your quality of life. The sleep
test (or Polysomnography) is usually covered by insurance as an outpatient procedure and is
completed with a short stay in the sleep lab.
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Dear Doctor,
A psychiatric evaluation of my patient is requested with respect to suitability for surgical treatment of Morbid
Obesity, by Roux-en-Y Gastric Bypass/Lap Band.
Please evaluate this patient with respect to:
•
•
•
•
•
Adverse psychiatric conditions: psychosis, severe neurosis, or severe behavioral disorder, which might
contraindicate surgery.
Unreasonable expectations or unrealistic goals.
Understanding of the risks and discomforts of surgery.
Ability to understand and comply with instructions and recommendations
Acceptance of the need for active participation in the therapy process for life.
The results of your evaluation will assist in determining the patient’s suitability for surgery and may also be made
available to an insurance carrier for determination of coverage eligibility.
Sincerely,
J. Stephen Scott, M.D., Medical Director, SSM Weight Loss Institute St. Louis
Roger A. de la Torre, M.D., Medical Director, SSM DePaul Weight Loss Institute
DPS-2065-988 (8/2009)
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
MENTAL HEALTH PROVIDERS
FOR BARIATRIC EVALUATIONS
Below is a list of mental health providers that offer weight-loss surgery evaluations. Patients
should always verify that the licensing for each particular provider meets the criteria on their
specific plans for metal health services provided for this service.
Anat Reschke, Ph. D.
10420 Old Olive Street Road
Suite 202
St. Louis, MO 63141
For an appointment call:
(314) 991-9700
C.J. Davis, Psy. D
116 South Lincoln
Troy, MO 63376
For an appointment call:
(636) 528-1996
Toll free (877) 221-8600
David Peaco, Ph. D.
600 Medical Drive
Suite 205
Wentzville, MO 63385
For an appointment call:
(636) 332-5050
Dianne Joyce, Psy. D.
12266 DePaul Drive
Suite 310
St. Louis, MO 63044
For an appointment call:
(314) 344-6800
Robert Becker, Ph. D.
13354 Manchester Road
Suite 220
St. Louis, MO 63131
For an appointment call:
(314) 994-7009
Lance Baugh, Ph. D.
50 Crestwood Executive Center
Suite 519
St. Louis, MO 63126
For an appointment call:
(314) 965-2415
Ronni Kahn, Ph.D.
12266 DePaul Drive
Suite 310
St. Louis, MO 63044
For an appointment call:
(314) 344-6800
Louise Kaufman-Yavitz, LPC, LCSW
1121 Olivette Executive Parkway
St. Louis, MO 63132
For an appointment call:
(314) 872-9988
DPS-2065-977 (8/2009)
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
MENTAL HEALTH REGISTRATION SHEET
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Patient Name: ________________________________________________ Today’s Date:_________________
SS#: _________________________________ DOB: _____________________ o M o F
Street Address:______________________________________________________________________________
City: _____________________________________________ State: __________ Zip:_ ____________________
Procedure: o Banding o Bypass o Other
Ht ________ Wt ________ Surgeon__________________
Phone # (home): _____________________ (work) _____________________ (cell)_ ____________________
o Married o Single o Widow/er
o Employed o Disabled o Retired
Employer: __________________________________________ How Long there?________________________
PAYMENT
Name of Primary Subscriber: _______­­_____________________________ DOB:_ ______________________
Address (if different than above):______________________________________________________________
Primary Insurance Co________________________________________________________________________
Insurance ID #__________________________________Group/Policy #______________________________
Authorization # (if required)___________________________________ # of visits authorized____________
Psych testing Authorization # (if required) see 3a on page 2______________________________________
Secondary Insurance Co Name_______________________________________________________________
Insurance ID #__________________________________Group/Policy #______________________________
Name and DOB of primary subscriber__________________________________________________________
Employer___________________________________________________________________________________
ASSIGNMENT OF BENEFITS: I hereby assign payment of authorized psychological benefits to the SSM Weight Loss Institute
provider for any and all psychological services provided. I authorize release of any information needed to determine the
benefits payable for related services. In accordance with my right to privacy, information will be shared only with those directly
associated with benefit determination and only as relevant to making benefit determination. A photocopy of this assignment
is to be considered as valid as the original. This assignment will remain in effect until revoked by me in writing. I understand
that I am financially responsible for chargers whether or not paid by said insurance. If this account is assigned to an attorney
or agency for collection and/or suit, I agree to pay the provider’s court cost and attorney’s fees. I give my consent for this
practitioner to render treatment on the above-mentioned patient for mental health services.
Signature: ___________________________________________ Date:_________________________________
As part of my managed care, I authorize my provider to exchange pertinent information with my primary care physician for
purpose of coordinated treatment, if and when deemed necessary.
Name of Primary Care Physician:______________________________________________________________
His/Her Phone #: __________________________________ Fax #:___________________________________
Patient Signature: ___________________________________________ Date:__________________________
DPS-2065-982 (8/2009)
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
PSYCH EVAL BACKGROUND INFORMATION
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
The following information is considered confidential
and will be handled as such.
Patient Name ________________________________________ DOB _______________ Age ______ ® Male ® Female
Your city and state ____________________________________________ Highest education level ___________________
Are you seeking: ® Banding ® Bypass Height _______________ Weight _______________
Married? _________ How long? _____________
Which marriage (2nd, etc.) _______ ® Single ® Widow/ed ® Divorced ® Separated
Who lives in your home? (wife, kids, etc.) _____________________________________ # of children born? _________
Employed where? __________________________ Job/position? _______________________ For how long? _________
What do you attribute your excess weight to? (e.g. poor food choices, genetics, large portions, etc.)
______________________________________________________________________________________________________
At what age or grade were you initially overweight? _______________ Highest weight ever? _____________________
Age or grade you made first dieting attempt _______________
If you recall, what did you weight when you graduated high school? _______________
Date of most recent dieting attempt (last year, currently dieting, etc.) _______________
Do you binge eat or consider yourself to be a compulsive eater? _______________
Are you a grazer (consistent snacker or picker)? _______________
Do you eat to compensate for stress _________ boredom _________ emotional comfort _________?
If yes to any of these, how do you plan on controlling these behaviors following weight loss surgery?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Have you ever had a suicide plan or attempt? ® Yes ® No If so, when? _____________________________________
List any current mental health diagnoses, such as depression, anxiety, etc. and any related medications:
______________________________________________________________________________________________________
Who prescribes the Rx and what is their phone number? ___________________________________________________
How many cigarettes do you smoke per day? _______________
How much alcohol do you drink and what type (beer, etc.)__________________________________________________
List any prior addictions ________________________________________________________________________________
Ever been hospitalized for a psychiatric disorder? _______________
Briefly describe your childhood when growing up (chaotic, stable, problematic, etc.) ___________________________
Do you regularly feel ® anxious ® nervous ® sad ® flat ® down ® helpless ® worthless ® guilty
Ever have a visual or auditory hallucination? _______________ Trouble sleeping? _______________
Does the desire to eat remain about the same over time? _______________
Currently under extreme stress? _______________ Ever treated for a eating disorder? _______________
Medical reasons for seeking bariatric surgery______________________________________________________________
______________________________________________________________________________________________________
How long have you been thinking about having a weight loss procedure? _______________
Ways you have researched the surgery ___________________________________________________________________
Any other family members who had bariatric surgery? ® Yes ® No
Who referred you for surgery (self/doctor) _______________
Briefly list the surgical risks of the procedure you are seeking _______________________________________________
______________________________________________________________________________________________________
What is the most you could weigh and feel like your surgery has still been successful?_________________________
DPS-2065-980 (6/2009)
12266 DePaul Drive
Suite 310
St. Louis, Missouri 63044
FEES FOR SERVICE AND PAYMENT
314.344.6800 Phone
314.344.6801 Fax
ssmweightloss.com
Please initial each paragraph in the provided space.
The purpose of the psychological evaluation is to help determine whether surgical weight loss is safe and
appropriate for any given patient. The following fees for service are due at the time of service regardless of the
evaluation outcome: Evaluation fee = not to exceed $165.00 Report Fee = $75.00 Psychological Testing = $75.00
to $125.00 and is generally billed to insurance.
OUT-OF-POCKET PATIENTS:
Both the evaluation and report fee is due in full at the time of service: The discounted fee will not exceed $225.00.
Testing beyond the PDSQ may be required at an additional fee. Initial ____________
INSURANCE PATIENTS:
Those who utilize their insurance benefits will be responsible for their co-pay and/or co-insurance and the report fee.
Patients who have a deductible, which has not been met, will need to pay for the evaluation and report fee in full at the
time of service and payment will be applied toward the deductible. Although insurance companies require a copy of
the report in making their determination to cover your surgery, INSURANCE COMPANIES CONSIDER THE REPORT A
NON-COVERED SERVICE and WILL NOT PAY FOR TIME TO COMPLETE THE REPORT UNDER ANY CONDITIONS.
Initial ____________
INSURANCE PATIENTS: Please complete and submit the following:
• Call the mental health number or the customer service number on your insurance card and complete the
following questions: this form must be returned prior to your appointment.
1.Is o Dianne Joyce o Ronni Kahn a provider in my network? ____________ (If not stop here and refer to out-ofpocket patient above)
2. My remaining deductible is ________________________
3. Do I need a separate authorization or pre-certification number for psychological testing? o Yes o No
3a. If yes, the authorization number for psychological testing is _____________________________________________.
4. My co-pay amount is ________________________
5. My co-insurance amount is ________________________
6. I spoke with _____________________________ at ________________________ insurance on (date)_________________.
Insurance quotation of benefits is not a guarantee of payment. Although it can take up to 2 months to hear from
insurance after filing for payment, patients are expected to cover any and all remaining fees denied payment by the
insurance company. Failure to pay would result in retraction of the report.
Initial ____________
Payment from both out of pocket payees and those utilizing insurance is due at the time of service in the form of cash
or money order. There is an ATM machine in the building lobby. Receipts will be provided for reimbursement of flex
accounts. Those who wish to utilize a credit card should get a cash advance on their card prior to evaluation.
Initial ____________
Insurance covers a one hour visit. Patients with extensive mental health histories may therefore require a second visit or
further psychological testing, in this case a second co-pay would be due but no additional report fee.
Initial ____________
I accept the above fees and payment conditions and agree to make such payment at the time of service.
___________________________________________
Signature
DPS-2065-981 (8/2009)
____________________
Date