Weight Loss Program Application Form Center East

Please follow the instructions provided in order to process your application.

If you have questions, please call The Hospitals of Providence Weight Loss Center East at 915-832-2485.

* indicates a required field

Patient Information

Patient's First Name

Patient's Last Name

Race

Gender:

Male
Femaile

Date of Birth

mm/dd/yyyy

Age

Street Address

City

State

Zip Code ^*

Home / Cell Phone

Please enter phone number without dashes (ex. 9017651000)

Marital Status

Married
Single
Divorced
Widowed

Patient's Occupation

Employer's Name

Email Address

Primary Care Physician

Pharmacy

Pharmacy Telephone Number

How did you hear about our program?

Referring physician
Family or Friend referral
Online Advertisement
Print Advertisement
Online Search
Social Media Ad
Other

Mobility needs

Do you have any mobility restrictions?
Are you in a wheelchair?
Do you use a scooter?
Would you need to be transported by stretcher to an appointment?

Responsible Party Information

Relationship to Patient

First Name

Last Name

Date of Birth

mm/dd/yyyy

Street Address

City

State

Zip Code

Home Phone

Work Phone

Employer

Insurance Information - A Copy of your insurance Card(s) - Front and Back - Is Required.

First Insurance

Select Insurance Preference

Insurance Company Name

Policy Number

Group Number

Phone Number

Policy Holder

Date of Birth

mm/dd/yyyy

Second Insurance
If you do not have a second insurance, please do not complete this section.

Insurance Company Name

Policy Number

Group Number

Phone Number

Policy Holder

Date of Birth

mm/dd/yyyy

In Case of Emergency Notify (Other Than Responsible Party)

Name

Select a choice

Address same as patient.

Street Address

City

Zip Code

State

Phone Number

Hospital History

Please list any hospital stays you have had

First Event

Previous Hospitalizations/Surgeries/Serious Illnesses

Date

Second Event

Previous Hospitalizations/Surgeries/Serious Illnesses

Date

Third Event

Previous Hospitalizations/Surgeries/Serious Illnesses

Date

Have you had previous weight loss surgery?

Do you have an abdominal mesh from a previous surgery?

Have you or any of your family members had any type of problem with anesthesia?

Weight History

BMI Calculator

Current Height

Feet and Inches

Current Weight

Pounds

How much weight do you expect to lose?

Pounds

Which procedure do you prefer?

Roux-en-Y Gastric Bypass
Sleeve Gastrectomy
Converting from Band

List your weight for each of the last 5 years.

Approximate age when you first seriously dieted:

How much water do you drink?

How many sodas (regular or diet) do you drink on average per week?

Do you ever drink caffeinated coffee or iced tea?

Do you ever drink decaffeinated coffee or iced tea?

Do you skip meals?

If you skip meals, which meals do you skip?

Breakfast
Lunch
Dinner
N/A

Are you lactose intolerant?

How many time do you go out to eat or get take out per week?

What type of food do you eat? (is it fast food restaurant?)

If you eat fast food, where and what exactly do you normally eat?

What size are you first serving portions?

Large
Small
Standard

How often do you return for second servings?

Rare
Sometimes
Always

If you do go back for seconds, what do you go back for? (a little of everything, starches, sweets, etc.?)

Do you consider your diet high in fats?

Do you consider your diet high in carbohydrates?

Are you a sweets eater?

If you are a sweets eater, what exactly do you like to eat? (Bread, chocolate, candies, ice cream, etc.)

Do you consider yourself an emotional eater?Select a choice

No
Yes, when depressed
Yes, when angry
Yes, when happy
Yes, when sad
Other

Is there something in your eating pattern that was not asked and you would like to share in your evaluation?

Sleep Disorders Screening Questionnaire

Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?

Do you often feel tired, fatigued, or sleepy during daytime?

Has anyone observed you stop breathing during your sleep?

Do you have or are you being treated for high blood pressure?

BMI more than 35k/m2?

Age over 50 years old?

Neck circumference >16 inches (40cm)?

Gender: Male?

Do you have sleep apnea?

Has anyone ever told you that you snore?

Has anyone ever told you that you stop breathing while sleeping?

Do you wake up with a headache?

Have you ever had a sleep study? If yes when/where?

Yes
No
Other

Do you use a BI-PAP or C-PAP machine? If so, what is the name?

Yes
No
Other

Medical History or Symptoms

Review of Symptoms: Please indicate any personal medical history below:

Genitourniary

Kidney Stones
Kidney Failure
Incontinence or Dribbling
Leakage of urine with coughing laughing or sneezing
On Dialysis
None

Psychological

Anxiety
Depression
Hospitalization for emotion problem.
None

Neurological

Stroke
Dizziness, vertigo
Numbness, tingling feelings, weakness
Tremors
Convulsions/Seizures
Loss of consciousness
Pseudotumor Cerebri
None

Endocrine

Thyroid Disease
Diabetes
Adrenal Gland Tumor
PCOS
None

Other Conditions

HIV / AIDS
Bleeding disorder
Blood clotting disorder
On Blood thinners / steroids
History of Blood Clots
Other

Other Conditions we should be aware of?

Medication Log

Allergies to Medications:

Allergies to Food:

Latex or Other Allergies:

Medication Log

Please include Medication and Dosage

Ex: (Z-Pac 500 MG)

Pharmacy's Name, Location, and Phone Number

Consent To Contact

On my home voice mail or answering machine

Initial if you accept

On my work voice mail or answering machine

Initial if you accept

On my cell phone voice mail

Initial if you accept

With persons who answer my home phone

Initial if you accept

Contact by E-mail:

Initial if you accept

If Accepted Please Include Email:

I authorize any member of the Center for Surgical Weight Loss staff to release any and all of my medical information to the Medical Director for Surgical Weight Loss Program.

Initial if you accept

I understand that personal information that is volunteered during group discussions in class and/or seminars will be kept within the group, and will not be repeated.

Initial if you accept

Please review our Notice of Privacy Practices and acknowledge receipt below:

Notice of Privacy Practices

--------------------------------------------------------------------------------------------------

Initial if you accept

Name:

Please print first and last name

Thank you for contacting The Hospitals of Providence Weight Loss Center East.

Patient Information

Responsible Party Information

Hospital History

Weight History

Medication Log

Weight Loss Services