Información del paciente (Required) Nombre Apellido Numero de telefono(Required)Numero de seguro social(Required) Altura (en pulgadas)(Required)Peso (en libras)(Required)Indice de Masa CorporalDireccion(Required) Numero y nombre de calle Ciudad AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Estado Codigo Postal Telefono de la CasaTelefono del TrabajoTelefono CelularDireccion de correo electronico Fecha de nacimiento(Required)Mes123456789101112Dia12345678910111213141516171819202122232425262728293031Año2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Edad(Required)Please enter a number from 15 to 100.Género(Required) Masculino Femenino Estado Civil Empleador Posicion/cargo Medico de Atencion primaria Numero de su doctor Informacion de seguro medicoPor favor incluya una copia de su tarjeta de seguro medico (del frente y de la parte de atras) para evitar retrasos en el proceso. Nombre del seguro primario Nombre del seguro Secundario Numero de Identidad del seguro primario Numero de identidad del seguro secundario Numero de grupo del seguro promario Numero de grupo del seguro secundario Servicio al cliente / Número de teléfono del proveedorServicio al cliente / Número de teléfono del proveedorNombre del suscriptor primario Nombre del suscriptor secundario Fecha de nacimiento del subscriptorMes123456789101112Dia12345678910111213141516171819202122232425262728293031Año2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Fecha de nacimiento del subscriptorMes123456789101112Dia12345678910111213141516171819202122232425262728293031Año2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Numero de Seguro Social del subscriptor Numero de Seguro Social del subscriptor Médicos que cuidan de usted(Required)NombreEspecialidadNumero de Telefono Add RemovePor favor haga clic en el signo "más" para agregar más médicos Historia de peso y dietaMi obesidad comenzo:En la infancia En la pubertad De adulto Despues del embarazo Despues de un evento traumatico Otro Factor Preguntas Generals Yo meriendo entre comidas Yo como porciones de comidas grandes en una sola sesión Yo como muchos dulces Yo tomo muchas sodas o té dulces Me he forzado a vomitar después de comer. Actualmente me forzo a mi misma a vomitar despues de comer. ¿Con qué frecuencia? Por favor haga una lista de los intentos previos que ha hecho para perder peso(Required)Programa o ModalidadFechasPeriodo de TiempoPerdida de Peso Add RemoveSea específico para la aprobación del seguro (Weight Watchers, Dieta, Medicamentos,etc. Por favor, haga click en el signo "más" para agregar más filas Yo he sido parte de un programa de dieta supervisado(Required) Si No Medically superverised diet programs(Required)FechasClinica/ Doctores Add RemovePlease click the "plus " sign to add more dates Historial MedicoEnfermedades del Corazon Angina Ataque al Corazon Bypass Coronario Angioplastia Colesterol Alto Presion Alta ¿Cuántos años?(Required) Diabetes ¿Cuántos años?(Required) Controlada con Dieta Insulina Medicamentos Asma Apnea del Sueño ¿Cuántos años? Fecha de su ultimo studio del sueño Ronca CPAP Soñoliento durante el dia Acides Estomacal ¿Cuántos años? Medicamentos Endoscopia Fecha de su ultimo studio Dolor en la espalda baja Dolor en las articulaciones Enfermedades de la Tiroides Le faltan dientes ¿Cuántos? Usa dentaduras Parciales Utilizo una silla de ruedas o una scooter todo el tiempo o la mayor parte del tiempo Historia de Fumar(Required) Actualmente Fumo Deje de Fumar Nunca he fumado Years as smoker(Required) Packs per day(Required) How long since you quit?(Required) Yo uso drogas recreacionales Tipo Ultima vez que consumio Yo consumo Alcohol Nunca Raramente Regularmente Cirugias previas(Required)ProcedimientoFechaComplicaciones Add RemovePor favor haga click en la señal de “mas” para agregar mas procedimientos Medicamentos que actualmente esta tomando(Required)Nombre del medicamenoDosisFrequencia Add RemovePor favor haga click en la señal de “ mas” para agregar mas medicamentos Alergias Soy Alergico/a al Latex Lista de alergiasIncluya alergias a medicamentos, comidas, ambiental, etc Historia FamiliarMadre Obesidad mórbida Diabetes Presion Alta Derrame Cerebral Ataque al Corazon ( Edad) Enfermedades del Corazon Cancer ( Edad/Tipo) Padre Obesidad mórbida Diabtes Presion Alta Derrame Cerebral Ataque al Corazon Endermedades del Corazon Cancer (Edad/Tipo) Hermanos Obesidad Morbida Diabetes Presion Alta Derrame Cerebral Heart Attack (Age?) Ataque al Corazon Cancer (Age/Tipo?) Informacion adicionalPor favor proporcione información adicional acerca de cualquier tipo cáncer o ataque cardíaco en su familia.Escriba su nombre mas abajo(Required) Mi firma confirma que he visto / asistido al seminario acerca de la cirugia de Banda Gastrica en su totalidad. Entiendo los riesgos y beneficios del procedimiento y entiendo que si tengo alguna pregunta con respecto al programa puedo comunicarme con la Oficina de Bariátrica al (502) 361-6059 Δ (Required) First Last Phone(Required)Social Security #(Required) Height (feet)Please enter a number less than or equal to 8.Height (inches)Please enter a number less than or equal to 11.HiddenHeight (in inches)(Required)Weight (in pounds)(Required)BMIAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Date of Birth(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)Please enter a number from 15 to 100.Gender(Required) Male Female Marital Status Employer Position Primary Care Doctor Phone Please tell us how you found usCheck all that apply Internet site/search Family member Friend Physician referral Newspaper Billboard Other Physician Name How you found us Insurance InformationPlease include a copy of your insurance card (front and back) to avoid a delay in processingPrimary Insurance Name Secondary Insurance Name Primary ID Number Secondary ID Number Primary Group Number Secondary Group Number Customer Service/Provider Phone NumberCustomer Service/Provider Phone NumberPrimary Subscriber Name Secondary Subscriber Name Subscriber DOBMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber DOBMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber SS# Subscriber SS# Physicians Caring for You(Required)NameSpecialtyPhone number Add RemovePlease click the "plus " sign to add more physicians Weight and Diet HistoryMy obesity started:In childhood At puberty As an adult After pregnancy After a traumatic event Other General Questions I snack between meals I eat large meals at one sitting (gorge) I eat a lot of sweets I drink regular soft drinks or "sweet" tea I have forced myself to vomit after eating (binge and purge) I am currently forcing myself to to vomit after eating How often? Please list prior attempts at weight loss(Required)Program or ModalityDatesLength of TimeWeight Loss Add RemoveBe specific for insurance approval (Weight Watchers, Diet, Medications, etc). Please click the "plus " sign to add more rows I have been part of a MEDICALLY SUPERVISED DIET PROGRAM(Required) Yes No Medically superverised diet programs(Required)DatesClinic / Physician Add RemovePlease click the "plus " sign to add more dates Medical HistoryHeart Disease Angina Heart attack CABG (coronary bypass) Angioplasty High cholesterol High blood pressure Number of years?(Required) Diabetes Number of years?(Required) Controlled with Diet Insulin Medication Asthma Sleep apnea Number of years? Date of last sleep study Snoring CPAP Daytime drowsiness Heartburn (GERD) Number of years? Medications Endoscopy Date of last scope Lower back pain Joint pain Thyroid disease Missing teeth How many? Dentures Partials I use a wheelchair or scooter all or most of the time Smoking History(Required) I currently smoke I have quit smoking I have not smoked Years as smoker(Required) Packs per day(Required) How long since you quit?(Required) I use "recreational" drugs Type Date last used I drink alcohol Never Rarely Regularly Previous Surgeries(Required)ProcedureDateComplication(s) Add RemovePlease click the "plus " sign to add more procedures Current Medications(Required)Drug nameDoseFrequency Add RemovePlease click the "plus " sign to add more medications Allergies I am allergic to latex List all allergiesInclude medications, foods, environmental, etc. Family HistoryMother Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Father Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Sibling Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Additional InformationPlease supply any additional information for any cancer or heart attack in your familyType your name below(Required) My signature confirms that I have viewed/attended the Lap-Band seminar in its entirety. I understand the risks and benefits of the procedure and understand that if I have any questions regarding the Program, I can contact the Bariatric Office at (502) 361-6059 Δ (Required) First Last Phone(Required)Social Security #(Required) Height (feet)Please enter a number less than or equal to 8.Height (inches)Please enter a number less than or equal to 11.HiddenHeight (in inches)(Required)Weight (in pounds)(Required)BMIAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Date of Birth(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)Please enter a number from 15 to 100.Gender(Required) Male Female Marital Status Employer Position Primary Care Doctor Phone Please tell us how you found usCheck all that apply Internet site/search Family member Friend Physician referral Newspaper Billboard Other Physician Name How you found us Insurance InformationPlease include a copy of your insurance card (front and back) to avoid a delay in processingPrimary Insurance Name Secondary Insurance Name Primary ID Number Secondary ID Number Primary Group Number Secondary Group Number Customer Service/Provider Phone NumberCustomer Service/Provider Phone NumberPrimary Subscriber Name Secondary Subscriber Name Subscriber DOBMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber DOBMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber SS# Subscriber SS# Physicians Caring for You(Required)NameSpecialtyPhone number Add RemovePlease click the "plus " sign to add more physicians Weight and Diet HistoryMy obesity started:In childhood At puberty As an adult After pregnancy After a traumatic event Other General Questions I snack between meals I eat large meals at one sitting (gorge) I eat a lot of sweets I drink regular soft drinks or "sweet" tea I have forced myself to vomit after eating (binge and purge) I am currently forcing myself to to vomit after eating How often? Please list prior attempts at weight loss(Required)Program or ModalityDatesLength of TimeWeight Loss Add RemoveBe specific for insurance approval (Weight Watchers, Diet, Medications, etc). Please click the "plus " sign to add more rows I have been part of a MEDICALLY SUPERVISED DIET PROGRAM(Required) Yes No Medically superverised diet programs(Required)DatesClinic / Physician Add RemovePlease click the "plus " sign to add more dates Medical HistoryHeart Disease Angina Heart attack CABG (coronary bypass) Angioplasty High cholesterol High blood pressure Number of years?(Required) Diabetes Number of years?(Required) Controlled with Diet Insulin Medication Asthma Sleep apnea Number of years? Date of last sleep study Snoring CPAP Daytime drowsiness Heartburn (GERD) Number of years? Medications Endoscopy Date of last scope Lower back pain Joint pain Thyroid disease Missing teeth How many? Dentures Partials I use a wheelchair or scooter all or most of the time Smoking History(Required) I currently smoke I have quit smoking I have not smoked Years as smoker(Required) Packs per day(Required) How long since you quit?(Required) I use "recreational" drugs Type Date last used I drink alcohol Never Rarely Regularly Previous Surgeries(Required)ProcedureDateComplication(s) Add RemovePlease click the "plus " sign to add more procedures Current Medications(Required)Drug nameDoseFrequency Add RemovePlease click the "plus " sign to add more medications Allergies I am allergic to latex List all allergiesInclude medications, foods, environmental, etc. Family HistoryMother Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Father Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Sibling Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Additional InformationPlease supply any additional information for any cancer or heart attack in your familyType your name below(Required) My signature confirms that I have viewed/attended the Lap-Band seminar in its entirety. I understand the risks and benefits of the procedure and understand that if I have any questions regarding the Program, I can contact the Bariatric Office at (502) 361-6059 Δ (Required) First Last Phone(Required)Social Security #(Required) Height (feet)Please enter a number less than or equal to 8.Height (inches)Please enter a number less than or equal to 11.HiddenHeight (in inches)(Required)Weight (in pounds)(Required)BMIAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Date of Birth(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)Please enter a number from 15 to 100.Gender(Required) Male Female Marital Status Employer Position Primary Care Doctor Phone Please tell us how you found usCheck all that apply Internet site/search Family member Friend Physician referral Newspaper Billboard Other Physician Name How you found us Insurance InformationPlease include a copy of your insurance card (front and back) to avoid a delay in processingPrimary Insurance Name Secondary Insurance Name Primary ID Number Secondary ID Number Primary Group Number Secondary Group Number Customer Service/Provider Phone NumberCustomer Service/Provider Phone NumberPrimary Subscriber Name Secondary Subscriber Name Subscriber DOBMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber DOBMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Subscriber SS# Subscriber SS# Physicians Caring for You(Required)NameSpecialtyPhone number Add RemovePlease click the "plus " sign to add more physicians Weight and Diet HistoryMy obesity started:In childhood At puberty As an adult After pregnancy After a traumatic event Other General Questions I snack between meals I eat large meals at one sitting (gorge) I eat a lot of sweets I drink regular soft drinks or "sweet" tea I have forced myself to vomit after eating (binge and purge) I am currently forcing myself to to vomit after eating How often? Please list prior attempts at weight loss(Required)Program or ModalityDatesLength of TimeWeight Loss Add RemoveBe specific for insurance approval (Weight Watchers, Diet, Medications, etc). Please click the "plus " sign to add more rows I have been part of a MEDICALLY SUPERVISED DIET PROGRAM(Required) Yes No Medically superverised diet programs(Required)DatesClinic / Physician Add RemovePlease click the "plus " sign to add more dates Medical HistoryHeart Disease Angina Heart attack CABG (coronary bypass) Angioplasty High cholesterol High blood pressure Number of years?(Required) Diabetes Number of years?(Required) Controlled with Diet Insulin Medication Asthma Sleep apnea Number of years? Date of last sleep study Snoring CPAP Daytime drowsiness Heartburn (GERD) Number of years? Medications Endoscopy Date of last scope Lower back pain Joint pain Thyroid disease Missing teeth How many? Dentures Partials I use a wheelchair or scooter all or most of the time Smoking History(Required) I currently smoke I have quit smoking I have not smoked Years as smoker(Required) Packs per day(Required) How long since you quit?(Required) I use "recreational" drugs Type Date last used I drink alcohol Never Rarely Regularly Previous Surgeries(Required)ProcedureDateComplication(s) Add RemovePlease click the "plus " sign to add more procedures Current Medications(Required)Drug nameDoseFrequency Add RemovePlease click the "plus " sign to add more medications Allergies I am allergic to latex List all allergiesInclude medications, foods, environmental, etc. Family HistoryMother Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Father Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Sibling Morbid Obesity Diabetes High Blood Pressure Stroke Heart Attack (Age?) Heart Disease Cancer (Age/Type?) Additional InformationPlease supply any additional information for any cancer or heart attack in your familyType your name below(Required) My signature confirms that I have viewed/attended the Lap-Band seminar in its entirety. I understand the risks and benefits of the procedure and understand that if I have any questions regarding the Program, I can contact the Bariatric Office at (502) 361-6059 Δ
