Baltimore Bariatrics
William J. Roe, Jr., M.D., F.A.C.S.
1001 Cromwell Bridge Road Suite 100
Towson, Maryland 21286
410-583-0123




Patient Name:                    Male    Female   
DOB:  (Enter in this format: ##/##/####)
Marital Status: S   M   W   D   Sep
Occupation:
Spouse/Significant Other's Name:
Phone # Home:  (Enter in this format: ###-###-####)
Work: Ext:   Cell:
Emergency Contact: Phone:

Email Address:

Do you have any spiritual practices, which you would like to inform us of; is there any religious belief that may impact your medical care?
 Yes        No

In the event of medical urgency, do you have religious beliefs for not accepting a blood transfusion?
Yes         No

What religion do you practice?

Social History:
Smoker:  Yes      No 
Cigarettes, Packs per day x years, Pipe, Cigar

Alcohol:
Social Drinker, Habitual Drinker # of Drinks per day/week/month/year

Patient Medical History:

When was your last physical exam? (##/##/####)

Sleep History:
Describe your sleep patterns: 


Have you ever had a sleep study? Yes No if yes, date of the study (##/##/####)
Do you use CPAP or BIPAP Yes No if yes, what is the pressure
Do you wake up gasping for breath Yes No
Do you fall asleep when sitting Yes No
Do you fall asleep when watching TV Yes No
Do you fall asleep when driving
 Yes No
      
Please check all that apply:
Respiratory:
Sleep Apnea COPD
Snore Asthma
Headaches TB
Wake up tired Emphysema
Stop breathing in sleep Bronchitis
Shortness of breath resting Pneumonia
Shortness of breath walking P.E.
Shortness of breath stairs Smoker

 Musculoskeletal:
Arthritis Gout
Knee pain Spinal Disc Problems
Chronic Fatigue Fibromylagia
Back Pain Fractured hip, wrist or spine
Other

Nervous System:
Neuropathy Stroke (CVA)
Dizziness Headaches/Migraines
Serious Problems with Memory Difficulty Thinking
Other Neurological Disorders 

Blood Disorders:
Anemia                                   Bleeding or clotting problems
Iron Deficiency Other  

Gastrointestinal:
Ulcers Diverticulosis
Chrohn's Disease Gallbladder Disease
Colon Polyps Hernia
Liver Disease Hemorrhoids
Change in Bowels Hepatitis
Reflux/GERD Dental Problems
Ulcerative Colitis

Cardiac:
Angina/Chest pain Congestive Heart Failure
High Cholesterol Irregular or Rapid Heart Beat
Heart Murmur High Blood Pressure
Coronary Artery Disease Heart Attack (year)
 
Endocrine:
Diabetes Hyperthyroid System
Hypothyroidism Voice changes
Visual Changes Increase in first Urination
Abnormal hair growth Irregular periods
Infertility Excessive Hot/Cold

Ear and Nose:
Cataracts Macular Degeneration
Sinus Infections Hay Fever
Wear Contacts Glaucoma
Hearing loss/Hearing aid Wear Glasses

Vascular:
Leg Ulcers Edema (swelling of legs)
Peripheral Vascular Disease

Breast:
Fibrocystic Disease Lumps (swelling of breasts)
Previous breast biopsy

Genitourinary:
Kidney Disease Prostate Disease
Kidney Transplant ( year) Difficulty Urinating
Frequent bladder or kidney infections Stress Incontinence
Urinating at Night (# of times ) Erectile Problems

OB / GYN:
Number of Pregnancies           Number of Children
Type of Delivery: # ?  Vaginal  Cesarean Section
Did you breast feed? Yes No        If yes, for how long? months
Date last menses: (##/##/####)  Date menopause (if applicable) (##/##/####)
Do you use contraception on a regular basis? Yes  No

Cancer:
Cancer Type: Year:
Treatment:

Do you have any other health concerns?


Do you have any food allergies/intolerances? Yes No

Are you currently taking vitamins? Yes No If yes, please list them:
                                                                                                              
                                                                                                             

Are you currently taking any herbal preparations or medications? Yes     No
If yes, please list them:
                                   

MEDICATIONS:
Please list all medications:
Medication Dose Times per day Purpose

Weight History:

Height Weight lbs.
Goal Weight: lbs. Age you were when last at goal weight
How would you classify your mother's weight?
Obese     Overweight Average      Below Average
How would you classify your father's weight?
Obese     Overweight Average     Below Average
How would you classify your weigth at age 5?
Obese     Overweight Average     Below Average
How would you classify your weight at age 15?
 Obese     Overweight Average     Below Average
How would you classify your weight at age 25?
Obese     Overweight Average     Below Average
How would you classify your weight at age 35?
Obese     Overweight Average     Below Average
How would you describe your weight at age 45 -60?
Obese     Overweight Average     Below Average
Are you currently at your highest weight? Yes           No

If not, what was your highest weight & when?

What is your expected weight loss with treatment?

Eating Behaviors:
Please check the following behaviors that have contributed to your Obesity.
Skip meals Detail:
Frequent snacking Detail:
Portion control Detail:
Eating too fast Detail:
Sweets (sugar, candy, cookies, ice cream) Detail:
Starches (breads, pastas, potatoes) Detail:
Fats (fried foods, butter, margarine) Detail:
Fast food Detail:
Emotional eating Detail:
Eat out of boredom Detail:
Binge eating Detail:
Purging/vomiting/laxatives Detail:

Please check the answer that best agrees with the following statements:

I eat large quantities of food:
Daily Several times a week Monthly Several times a year Never

When I eat large quantities of food I feel I cannot stop.
Daily Several times a week Monthly Several times a year Never

I eat until I feel uncomfortably full.
Daily Several times a week Monthly Several times a year Never

I eat large amounts even when I am not really hungry.
Daily Several times a week Monthly Several times a year Never

I eat continuously with no planned mealtimes.
Daily Several times a week Monthly Several times a year Never

I eat alone because I am embarrassed by how much I eat.
Daily Several times a week Monthly Several times a year Never

I cannot determine when I am actually physically hungry.
Daily Several times a week Monthly Several times a year Never

I have used diuretics to lose weight.
Daily Several times a week Monthly Several times a year Never

I have used laxatives to lose weight.
Daily Several times a week Monthly Several times a year Never

I have vomited to lose weight.
Daily Several times a week Monthly Several times a year Never

Are you currently following a diet? Yes    No    If yes please indicate the type of diet:


How many meals per day do you eat?
How many snacks do you eat per day?
Who plans your meals?
Do you eat breakfast regularly? Yes    No
List the beverages you drink mostly:
 

Do you drink water? Yes    No    If yes, how much per day? cups

What are your worst food habits?


Which food do you crave the most?
How often do you eat at fast food restaurants?

Do you eat fast food, which restaurants do you frequent?
 

Diet History:
Have you ever been on any physician supervised diet programs? Yes       No
Do you have any documentation of weight loss attempts?   Yes        No

Please list all prescription medications you have ever taken.

Program/Plan Starting Date Ending Date Loss/Gain Lbs
Phentermine
Fen-Phen
Meridia
Xenical
Fasten
Adipex
Other
Other

Please list any diet programs/and attempts that you can remember; starting with the most recent.

Name Start Date End Date Start Weight Lbs lost
Adkins
Jenny Craig
Weight Watchers
L.A. Weight Loss
Nutrisystem
Metabolife
Metabotrim
OTC products
Other:  
Other:  

Physical Activity Assessment

How did you get here today (only applicable if intending on delivering patient form physically to the office)?  drove myself
family member drove me    public transportation        other (if online form submission this option is applicable)

Are you currently exercising? Yes    No

Have you participated in an exercise program in the past? Yes        No

Please list any activities that you are unable to perform due to your weight.
1.
2.
3.
4.
5.

How important do you feel that exercise will be in your weight loss?
Vital        Essential           Fairly important        Not important

Please rate daily activities:
1 = difficult        2 = somewhat challenging        3 = easy

Getting out of bed
Getting dressed
Sleeping flat
Putting on shoes/socks
Walking up/down stairs
Daily household activities
Driving
Walking around home
Walking in general
Shopping
Total score:

Are you currently employed? Yes        No

With whom do you live?

Please list activities that you would like to do if you were physically able
1.
2.
3.

Additional information you would like us to know:


Medical Providers:

We need to maintain contact with all of your health care providers to keep them informed of your condition.
Please complete the list below.

Primary Care Physician:
    Phone:     Fax:
Address:


Pulmonologist:
    Phone:     Fax:
Address:


Cardiologist:
    Phone:     Fax:
Address:


Endocrinologist:
    Phone:     Fax:
Address:


Orthopedist:
    Phone:     Fax:
Address:


Neurologist:
    Phone:     Fax:
Address:


Gastroenterologist:
    Phone:     Fax:
Address:


Gynecologist:
    Phone:     Fax:
Address:


Other not listed:
    Phone:     Fax:
Address:


Other not listed:
    Phone:     Fax:
Address:


                                                                          

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Baltimore Bariatrics
1001 Cromwell Bridge Rd.
Towson, MD 21286
(410) 583-0123

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