Dr. Emad Guirguis

Dr. Emad Guirguis
149 Bayfield St, Barrie, ON, L4M 3B3
Office: (705) 737-3933 Fax: (705) 737-1176
www.lakeviewsurgery.com
Bariatric Referral Form
Referring Physician Information (Please Print)
Referring Physician’s Name
Phone #
Billing #
Referral Date
(dd/mm/yyyy)
Patient Information (Please Print)
Surname
Given Name
Street Address
Home Telephone #
Date of Birth
(dd/mm/yyyy)
City
Business Telephone #
Postal Code
Health Card #
Reason for Referral
Current Weight: ________________  lb.  kg.
 Actual  Estimated
Current Height: ________________  cm.  inches
 Actual  Estimated
Calculated BMI: ________________
Patient’s Weight Loss Goals: ___________________________________________________
Obesity to discuss Bariatric Management, including: Laparoscopic Adjustable Gastric Band,
Gastric Bypass and Gastric Sleeve.
Does Patient currently have a LAP Band?
 Yes  No
If yes, is patient interested in the Re-Entry Program for Medical Management and LAP Band
Revisions and Adjustments?
 Yes  No
Past Medical History
Medical/Surgical History, Previous Weight Loss Surgery: ______________________________
_____________________________________________________________________________
Previous problems with anesthesia (ie; Malignant Hyperthermia, Difficult Intubation, etc): ____
_____________________________________________________________________________
Medication List: _______________________________________________________________
_____________________________________________________________________________
Allergies: ____________________________________________________________________
_____________________________________________________________________________
Please fax completed forms to (705) 737-1176
Dr. Emad Guirguis
149 Bayfield St, Barrie, ON, L4M 3B3
Office: (705) 737-3933 Fax: (705) 737-1176
www.lakeviewsurgery.com
Past Medical History (Questions Regarding Patient’s Health History)
1. Does the patient have any psychiatric illness?  Yes  No
2. Does the patient have a history of substance abuse?  Yes  No
 Alcohol  Smoking  Other Drugs  N/A
3. Has the patient had previous liposuction?  Yes  No
4. Does the patient’s current weight cause significant issue when performing their daily
activities or employment duties?  Yes  No
5. Is the patient’s current weight preventing joint replacement surgery?  Yes  No
6. Has the patient tried the behavioral programs that conform with the Canadian Clinical
Practice Guidelines on management of obesity?  Yes  No
7. Does the patient have Type-2 Diabetes of impaired glucose fasting?  Yes  No
Currently controlled by medication?  Yes  No  N/A
8. Does the patient have hypertension?  Yes  No
Currently controlled by medication?  Yes  No  N/A
9. Does the patient have dyslipidemia?  Yes  No
Currently controlled by medication?  Yes  No  N/A
10. Does the patient have sleep apnea?  Yes  No
Currently controlled by medication?  Yes  No  N/A
11. Does the patient use a CPap device?  Yes  No
Currently controlled by medication?  Yes  No  N/A
12. Does the patient have gastroesophageal reflux (GERD)?  Yes  No
Currently controlled by medication?  Yes  No  N/A
13. Does the patient have end stage renal disease or require dialysis?  Yes  No
Currently controlled by medication?  Yes  No  N/A
14. Does the patient have severe cardiac or respiratory disease?  Yes  No
Currently controlled by medication?  Yes  No  N/A
15. Does the patient have liver disease?  Yes  No
Currently controlled by medication?  Yes  No  N/A
16. Does the patient have history of family history of auto immune disorder?  Yes  No
Currently controlled by medication?  Yes  No  N/A
_________________________________________________
Referring Physician (Please Print)
__________________
Date
_________________________________________________
Referring Physician Signature
__________________
Date
Please fax completed forms to (705) 737-1176