Patient Packet - Journey Clinic

Transcription

Thank you for your interest in our weight loss surgery program! If you would like to
view more information about our clinic or weight loss surgery, we encourage you to visit us
online at www.journeyclinic.com. Feel free to view our online seminar or attend one of our
live seminars. Please feel free to contact us if you have any questions 405-735-2049.
You can use the following checklist to help get started:
___ View our seminar
___ Complete attached Weight Loss Surgery Patient Packet and submit
___ Submit legible copy of the front and back of your insurance card(s)
___ Submit legible copy of picture id
Feel free to mail or drop off the completed information at our office location:
3400 W. Tecumseh Rd Ste 105
Norman, OK 73072
or
or
Email: [email protected]
Fax 405-307-5630
To find out more information, visit us online at www.journeyclinic.com
3400 W. Tecumseh Ste 105 Norman, OK 73072405-735-2049
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Oklahoma Surgical Associates
Doctors Park Building
500 East Robinson, Suite 2300
Norman, OK 73071
Office: (405) 329.4102
Fax:
(405) 307.5625
Journey Clinic
3400 W. Tecumseh Rd., Suite 105
Norman, OK 73072
Office: (405) 735.2049
Fax:
(405) 307.5630
James R. McCurdy, M.D.
Tom Shi Connally, M.D.
John B. Chace, M.D.
Lana Nelson, D.O.
M. Daniel Isbell, M.D.
Kerri Baker, PA-C
Amanda Lewis, PA-C
Kim Martens, ARNP
Lara Green, PA-C
Contract for Narcotic Prescriptions
Controlled substance medications (Narcotics, Opiates, Tranquilizers, and Barbiturates) can be useful to treat some painful
conditions, but have a high potential for misuse and abuse and are therefore closely controlled by the government. If used
excessively, they can cause adverse affects such as impaired judgment, vomiting, constipation, lethargy and even death. To insure
that these medications are used properly to treat my pain, I agree to follow the instructions listed below. I understand that if I do
not abide by these instructions and conditions, the prescribing of my narcotic pain medication and my entire treatment at
Oklahoma Surgical Associates will be discontinued.
1. I am responsible for my narcotic medication. If the prescription or the medication itself is lost, misplaced or stolen, or if I run out
too soon, the medication is gone and will not be replaced. I will not increase the dose (take more than prescribed) of my medicine
without first discussing it with the physician. Requests for early refills will be denied and if the requests continue, my treatment
with Oklahoma Surgical Associates will be terminated.
2. Refills of narcotics will be made only during business hours.
Narcotic refills are filled Monday- Thursday 8:30-4:00.
Refill requests will not be taken on Fridays. When requesting refills please provide the nursing staff with your pharmacy name and
phone number. Refills of narcotic medications will not be made after hours, on the weekends or on holidays. The answering
service will not contact the doctor for refills. It is my responsibility to contact the office 24-48 hours prior to using the last of my
medicine to ensure that I do not run out. Narcotic medications will only be given at time of surgery or at the doctor’s discretion.
After that time, it is my responsibility to find a physician to take over that care if necessary. I understand that stopping my
medicine supply may be dangerous to my health and cause serious withdrawal symptoms. I understand that narcotic prescriptions
may be required to be picked up and a photo ID will be required before the prescription will be released. If a person other than me
will pick up the prescription, that person will be required to bring his/her photo ID and a note from myself authorizing my
medication to be released.
3. I will not request nor accept narcotic medication from any other physician and/or other individual while I am receiving such
medication from this office. If I must go to the emergency room and/or hospital for any actual emergency and if at that time I am
given a narcotic prescription, I will notify this office within 24 business hours. I understand that it is ILLEGAL to obtain narcotic
medication from multiple physicians. It is also illegal to accept medications from other individuals or to share my medicine.
4. I have been informed by my physician about narcotic effects, including normal physiological effects of tolerance (need for more
medicine to achieve the same pain relief) and dependence (an uncomfortable withdrawal reaction which may occur if I stop taking
the medicine abruptly) and the abnormal effect of addiction (psychological dependency leading to abnormal behavior), which is
very rare in patients with genuine pain. Narcotics can adversely affect my judgment in making business decisions and in operating
equipment, such as an automobile
5. I understand that if I violate ANY of the above instructions or conditions:
My narcotic prescriptions and my entire treatment at Oklahoma Surgical Associates WILL BE TERMINATED IMMEDIATELY.
Any violation of this contract will be reported to any other physician and to local medical facilities involved in my care.
Any violations of State or Federal Law will be reported to the authority.
__________________________________________________
Patient Name (Please Print)
____________________________
Date of Birth
_________________________________________________
Signature
____________________________
Date
Oklahoma Surgical Associates
The following information is very important to your health.
Please take time to fully and completely fill out this important information.
Patient Name: __________________________________
Date of Birth:_______________________________
Primary Care Physian:____________________________
Referring Physician:__________________________
Reason for Visit Today:___________________________
Physician:__________________________________
Review of Systems: (please mark all that apply to you)
Systemic
___Weakness
___Tiredness
___Weight Loss
___Weight Gain
___Trouble Sleeping
___Fever
Eyes
___Blurred Vision
___Glasses/Contacts
Ears/Nose/Mouth
___Difficulty Hearing
___Ringing in Ears
___Recurrent Infection
___Sinus Problems
___Nose Bleeds
___Post Nasal Drip
___Mouth Sores
___Bleeding Gums
___Sour Taste
___Bad Breath
Throat
___Lump in Throat
___Hoarseness
___Swollen Glands
___Sore Throat
___Difficulty Swallowing
Cardiac
___Chest Pain
___Chest Tightness
___Heart Palpitations
___Swollen Feet/Ankles
Respiratory
___Cough
___Snoring
___Difficulty Breathing
___With Walking
___Climbing Stairs
___Laying Flat
Gastrointestinal
___Abdominal Pain
___Bloating
___Excessive Gas
___Loss of Appetite
___Nausea
___Vomiting
___Problems Swallowing
___Heartburn
___Blood in Stool
___Constipation
___Diarrhea
___Mucous in Stool
___Pain in Rectum
___Jaundice
___Change in Appetite
Skin/Breast
___Cyst in Breast
___Lump in Breast
___Breast Pain
___Rash
___Hives
___Lesion, Mole
___Itching
___Change in Skin Color
___Change in Nails
___Change in Hair
Hematologic
___Slow Healing
___Easy Bruising
___Swollen Glands
___Varicose Veins
Neurologic/Psych
___Dizziness
___Seizures
___Numbness
___Frequent Headaches
___Depression
___Anxiety
Endocrine
___Excessive Thirst
___Heat Intolerance
___Cold Intolerance
Gynecologic-Women
___Irregular Periods
___Heavy Periods
___Painful Periods
___No Periods
Genitourinary
___Frequent Urination
___Painful Urination
___Blood in Urine
___Dark Urine
___Urine Leakage
___Nighttime Urination
Musculoskeletal
___Pain in Joints
___Back Pain
___Difficulty Walking
Patient Name:______________________________________
Date of Birth:____________
Page 2
Surgical History: (Please mark if any applies to you)
___Abdominal
___Appendectomy
___Breast Surgery
___Colon Surgery
___C-Section
___Gallbladder
___Groin
___Heart Bypass
___Heart Cath
___Neck Surgery
___Hernia
___Abdominal
___Groin
___Hiatal
___Hysterectomy
___Joint Surgery
___Lung Surgery
___Open Heart Surgery
___Prostate Surgery
Other: _______________
___Spine Surgery
___Thyroid Surgery
___Tonsillectomy
___Tubal
___Weight Loss Surgery
___ Gastric Bypass
___ Sleeve Gastrectomy
___Switch
___Adjustable Gastric Band
___Other
Past Medical History: (Please mark all that apply to you)
___Heart Valve Problems
___asthma
___gallstones
___Hypertension
___emphysema
___cirrhosis of liver
___Congestive Heart Failure
___bronchitis
___hepatitis
___coronary heart disease
___pneumonia
___fatty liver
___peripheral vascular disease
___sleep apnea
___anxiety
___leg swelling or ulcers
___pulmonary hypertension
___depression
___HIV
___osteoporosis
___gastroesophageal reflux
___glaucoma
___osteoarthritis
___laryngopharyngeal reflux
___stroke/mini-stroke
___degenerative disc disease
___peptic/stomach ulcer
___high cholesterol/lipids
___gout
___crohn's disease
___high triglycerides
___rheumatoid arthritis
___colitis
___diabetes
___fibromyalgia
___pancreatitis
___pre-diabetes
___enlarged prostate
___epilepsy
___metabolic syndrome
___kidney stones
___bipolar disorder
___chronic sinusitis
___kidney insufficiency/failure
___blood clots
___allergies
___thyroid disorder
___in legs
___vitamin deficiency
___pituitary disorder
___in lungs
___anemia
___adrenal disorder
___hemophilia
___polycystic ovaries
___Hernia
___hiatal
___abdominal
___tuberculosis
___cancer
Type:________________
Patient Name:______________________________________
Page 3
Social History : (please mark all that apply to you)
Marital Status:
___Single
Work History:
___Student
Living Status:
___Live Alone
___Live with someone
Exercise:
___Daily
___Occasionally
____Rarely
___Never
Caffeine use:
___Coffee
___Tea
___Soda
___Total cups (8oz) per day
Tobacco Use:
Do you use tobacco/nicotine?
___Married
___Divorced
___Self-Employed
___Never
___Employed
___Currently
___Widowed
___Unemployed
___Previously
___Disabled
___Retired
Date quit? ___________________
If currently, what type:
___Cigarettes ___Cigars ___Vapor ___Oral tobacco
If currently, how often is your use ?
___Everyday ___Some days, but not every day ___Socially
How many cigarettes/cigars do you smoke a day ?
___5 or less ___6-10 ___11-20 ___21-30 ___31 or more
After waking, when do you smoke your first cigarette?
___within 5 minutes ___6-30 minutes___ 31-60 minutes___after 60 minutes
Are you interested in quitting ?
___Ready to quit
___Thinking about quitting
Alcohol Use:
Did you have a drink containing alcohol in the past year ?
___Yes
___Not ready to quit
___No
If yes, how often did you have a drink containing alcohol in the past year ?
___2 to 4 times a month ___ 2 to 3 times a week ____4 or more times a week
If yes, how many drinks did you have on a typical day when you were drinking in the past year ?
___1 to 3 drinks ___4 to 6 drinks
___ 7 to 9 drinks ___ 10 or more
If yes, how often did you have 6 or more drinks on one occasion in the past year ?
___Never Less than monthly ___Monthly ___Weekly ___Daily or almost daily
Recreational Drug Use:
Have you used drugs for other than medical reasons in the past 12 months ?
Have you ever used street drugs ? ___Never
___Currently
___Yes ___No
___Within last 12 months
If yes, type _________
___IV use ___Oral use
Patient Name:______________________________________
Page 4
Family History: (complete to the best of your knowledge)
___ I am adopted and do not know my family medical history
Father
Mother
Siblings
Children
___Living
___Deceased
___Living
___Deceased
___Living
___Deceased
___Living
___Deceased
___bleeding disorders
___breast cancer
___colon cancer
___diabetes
___heart disease
___high blood pressure
___lung disease
___ovarian cancer
___prostate cancer
___thyroid disorder
___breast cancer
___colon cancer
___diabetes
___heart disease
___lung disease
___ovarian cancer
___prostate cancer
___thyroid disorder
___breast cancer
___colon cancer
___diabetes
___heart disease
___lung disease
___ovarian cancer
___prostate cancer
___thyroid disorder
___breast cancer
___colon cancer
___diabetes
___heart disease
___lung disease
___ovarian cancer
___prostate cancer
___thyroid disorder
Previous Exams: (list most recent date obtained)
Exam Type
Complete Physical
Bone Density Scan
Stress Test
Heart Catherterization
Upper Endoscopy
Colonoscopy
Prostate Exam
Pap Smear
Mammogram
Yes / Year
Facility
Never
Patient Name:______________________________________
Preferred Pharmacy you use:
Current medications:
Page 5
_______________________________________________________________________
(Please include non-prescription medications, vitamins, supplements, creams, eye drops and inhalers)
Medication Name:
____________________________________________
Dosage:
_____________
Times taken daily:
___________________
____________________________________________
_____________
___________________
____________________________________________
_____________
___________________
____________________________________________
_____________
___________________
____________________________________________
_____________
___________________
Medication allergies:
Reaction:
____________________________________________
____________________________
____________________________________________
____________________________
____________________________________________
____________________________
Food allergies:
____________________________________________
____________________________
____________________________________________
____________________________
____________________________________________
_____________________________
Latex allergy:
___Yes
___No
Height: __________ Weight: __________
The questions on this form have been accurately answered to the best of my knowledge.
I understand that providing incorrect information may be dangerous to my health.
It is my responsibility to inform the doctor’s office of any changes in my medical status.
Patient Signature_______________________________________________________Date: _______________
Relationship to Patient (circle one):
Self
Parent
Guardian
POA
FOR OFFICE USE ONLY:
Physician's statement: I have reviewed the information and made additions or corrections as necessary.
Physician Signature: __________________________________________________________ Date: _________
BARIATRIC SUPPLEMENTAL QUESTIONNAIRE
The following information is very important to your health. Please take
time to fully and completely fill out this important information.
Last Name:_______________ First Name:________________ DOB: ___/___/___
HEALTH CARE PROVIDERS
Please list all providers for the past five years including Specialist and Mental Health
MAY WE CONTACT?
PHYSICIAN NAME:
ADDRESS:
YES
NO
YES
NO
YES
NO
YES
NO
PHONE NUMBER:
TYPE OF PROVIDER:
PHYSICIAN NAME:
ADDRESS:
PHONE NUMBER:
TYPE OF PROVIDER:
PHYSICIAN NAME:
ADDRESS:
PHONE NUMBER:
TYPE OF PROVIDER:
PHYSICIAN NAME:
ADDRESS:
PHONE NUMBER:
TYPE OF PROVIDER:
WEIGHT LOSS ATTEMPTS
Please Record all previous weight loss attempts, diets, etc.
PROGRAM
WEIGHT WATCHERS
JENNY CRAIG
HIGH PROTEIN/LOW
CARB (ATKINS,
SOUTHBEACH
NUTRI-SYSTEM
OVER THE COUNTER
DIET PILLS
PHENTERMIN (ADIPEX,
FASTIN, ETX)
FENFLURAMINE/PHENTE
RMINE FEN/PHEN
MERIDIA OR XENICAL
SLIMFAST OR SIMILAR
HYPNOSIS, JAW
WIRING, ACUPUNCTURE,
EAR STAPLING
OTHERS (LIST)
PROGRAM WEIGHT WEIGHT
DATES
LOSS REGAINED
HOW
PHYSICIAN DIETITIAN
LONG
SUPERVISED SUPERVISED
TO
Y/N
Y/N
REGAIN
FUNCTIONAL STATUS
Circle your highest level of functioning.
Walk without assistance
Walk a block with assistance (cane/walker)
Walk around house with assistance (cane/walker)
Require wheelchair
Bedridden
SLEEP QUESTIONNAIRE
Check all that apply
____ I have been told that I snore
____ I have been told that I stop breathing while I sleep
____ I suddenly wake up unable to breathe
____ I frequently toss and turn during sleeping hours
____ I don’t feel well rested when I wake up
____ I frequently take naps during the day
____ I feel fatigued/tired during the day
____ I have difficulty with long periods of concentration
____ I suffer from morning headaches
____ I have problems with memory loss
____ My family and friends say that they have noticed that I am more irritable
FACTORS THAT HAVE CONTRIBUTED TO NOT ACHIEVING WEIGHT LOSS
Check all that apply
____ Lack of Exercise
____ Eating Sweets
____ Eating Large Quantities
____ Stress Eating
____ Eating Carbohydrates
____ Eating Out
____ Snacking
____ Grazing
Patient statement: I have completed this form as accurately as possible. All of the
information contained in this history form is accurate and complete to the best of my
knowledge. I understand if any changes occur I am responsible for notifying my physician of
these changes, as it may have an impact on my health.
______________________________
Signature of patient
_____________________
Date completed
Seminar Questionnaire
Name:___________________________________________
Last Physician Recorded: Height_______________
DOB:_______________________
Weight:________________ BMI:____________
CIRCLE if you are currently being TREATED for:
High Blood Pressure
High Cholesterol
Diabetes
Arthritis of the weight bearing joints
Sleep Apnea
Degenerative Disc Disease
HAVE you been a part of a weight loss surgery program in the past?
YES
NO
Name of Program:__________________________________________________________________
HAVE you previously had weight loss surgery?
Type:___________________________________
YES
NO
Date:___________________________
May we contact your insurance company to predetermine benefits for weight loss surgery?
YES
NO
Which procedure would you like to pursue?
Gastric Bypass
Sleeve Gastrectomy
Adjustable Gastric Band
_____I have watched the complete Weight Loss Surgery Seminar series on Journey Clinic’s website.
Initials
Patient Signature: _______________________________________
Date:_____/_____/_____
We Would Like To Know....
What factor(s) made you decide to pursue weight loss surgery? (Check all that apply)
[ ] Improve Health Condition(s)
[ ] Become More Active
[ ] Lose Weight
[ ] Physician Recommendation
[ ] Friend/Family Recommendation
[ ] Other: _____________________________
What factor(s) made you decide to pursue weight loss surgery with Journey Clinic?
(Check all that apply)
[ ] Procedure
[ ] Surgeon/Staff
[ ] Timeliness
[ ] Insurance
[ ] Facility
[ ] Recommendation (friend/family/health care
provider, etc)
[ ] Other: _____________________________
How did you hear about Journey Clinic? (Check all that apply)
[ ] Internet Search
[ ] Referred by Friend
[ ] Referred by Primary Care Physician
[ ] Referred by Specialist
[ ] Saw Clinic While at Another Appointment
[ ] Saw / Heard Advertisement
(Describe): ___________________________
[ ] Other: _____________________________
What websites do you use when researching Weight Loss Surgery? (Check all that
apply)
[ ] Google/Yahoo/Bing/Etc.
[ ] obesityhelp.com
[ ] lapband.com
[ ] journeyclinic.com
[ ] normanregional.com
[ ] other:______________________________