DATE: ______

SELF
LAST NAME FIRST MI MAIDEN
ADDRESS
CITY STATE ZIP
SOCIAL SECURITY NUMBER
DATE OF BIRTH AGE
MALE  FEMALE  MARRIED  DIVORCED  WIDOWED  SEPARATED  NEVER MARRIED 
RACE: WHITE  AFRICAN AMERICAN  HISPANIC  ASIAN  NATIVE AMERICAN/ALASKAN NATIVE  OTHER 
CAN BE REACHED OR MESSAGE LEFT AT HOME # DURING THE DAY? YES  NO  HOME PHONE#
CAN BE REACHED OR MESSAGE LEFT AT WORK # DURING THE DAY? YES  NO  WORK PHONE#
CAN BE REACHED OR MESSAGE LEFT AT CELL # DURING THE DAY? YES  NO  CELL PHONE#
DO YOU WISH TO RECEIVE COMMUNICATION VIA E-MAIL ? YES  NO  EMAIL:
EMPLOYER OCCUPATION
SPOUSE
LAST NAME FIRST
SOCIAL SECURITY NUMBER DATE OF BIRTH
EMPLOYER
YOUR PRIMARY CARE PHYSICIAN
FAMILY PHYSICIAN
DATE OF LAST VISIT
ADDRESS
PHONE FAX
PHYSICIAN WHO REFERRED YOU TO US
REFERRING PHYSICIAN
ADDRESS
PHONE FAX
ARE YOU ALREADY A PATIENT OF / WORKING WITH:
The Center for Lifestyle Medicine / YES  / NO 
Dr. Courtney Noble / YES  / NO 
Name: / Date:
AUTHORIZATION FOR RELEASE OF INFORMATION
I authorize the physician and outpatient staff in attendance on this case to release medical information to the pertinent insurance company (s) or third party carriers and request payment to be made directly to the billing entity. I understand that I am financially responsible for any balance not covered by the insurance carrier (s). I also request that payment of benefits from my policy ______(Medigap/other be paid directly to the billing entity until otherwise notified.
______
Signature Signature of parent (if minor)
PRIMARY INSURANCE COMPANY
INSURANCE CO. NAME
ADDRESS
CITY / STATE / ZIP
POLICYHOLDER’S NAME
RELATIONSHIP TO PATIENT
POLICY NUMBER
CUSTOMER SERVICE PHONE NUMBER
PROVIDER INQUIRY/PRECERTIFICATION PHONE NUMBER
CONTACT PERSON
IS GASTRIC BYPASS AND/OR LAP-BAND FOR “MORBID OBESITY” A COVERED BENEFIT?
YES  NO 
SECONDARY INSURANCE COMPANY
NAME
ADDRESS
CITY / STATE / ZIP
POLICYHOLDER’S NAME
RELATIONSHIP TO PATIENT
POLICY NUMBER / GROUP/PLAN NUMBER
CUSTOMER SERVICE PHONE NUMBER
PROVIDER INQUIRY/PERCERTIFICATION PHONE NUMBER
CONTACT PERSON
NAME: DATE:
SURGERY OPTIONS
Please circle the surgery below that you are interested in having:
Gastric Bypass (Open or Laparoscopic) Lapband Revision

MEDICAL INFORMATION

Do you have, or have you had, any of the following:

√ √

Diabetes / Frequent constipation or difficulty with evacuation
High blood pressure / Frequent diarrhea or fecal incontinence
High cholesterol / Crohn’s disease_____colitis______
Chest pain or angina / Irritable bowel syndrome
Heart Failure / Hernia, what Kind:
Hear attack, when? ______/ Blood clot or clotting disorders: where? ______
When? ______
Heart disease / Bowel incontinence
Asthma / Headaches, how often:
Sleep apnea
Do you use (circle) CPAP BiPAP / Thyroid disease
Do you use Oxygen Yes No / Fatty liver disease
How many Liters? / Hepatitis B or C:
How many hours/day do you use oxygen? / HIV
Cancer, what kind:
When:
Treatment (circle) Surgery Radiation Chemotherapy / Women: last menstrual cycle, Date:
Menopause: Yes No
Arthritis, joint pain / Lupus
Gallbladder trouble / Polycystic ovarian syndrome (PCOS)
Heartburn, indigestion/GERD / Use wheelchair or scooter: Yes No
Stomach ulcers / How many hours per day?______
/ How far do you walk in a normal day?______
How many steps can you climb?:
How many steps do you climb daily?
Other:
NAME: DATE:
PREGNANCIES, INCLUDING DATE:
DATE / Indicate if full term, premature,C-section, etc. / DATE / Indicate if full term, premature,C-section, etc.

SURGICAL INFORMATION

DATE / SURGERY /
On the diagram to the right, please indicate the location of any surgical incisions (scars from surgeries) that you have.
Allergies: Are you allergic to any drug, food, or substance? If yes, what happens when you take or are exposed to it (example: penicillin ---- get a rash)
Tobacco products: Do you use any tobacco products? YES  NO 
If yes, what kind?
how often?
what year did you start? Quit date:
Alcohol: How much of the following do you drink per week?
Mixed drinks (1 oz/drink) / Beer (12 oz) / Wine (6 oz glass)
NAME: DATE:

MEDICAL INFORMATION

What medications do you take on a regular basis? Please list your prescription medications first, then any over-the-counter (e.g., Tylenol, Ex-Lax, etc), herbal (e.g., St. John’s Wort, glucosamine-chondroitin), or vitamin-mineral supplements (e.g., Calcium, One-A-Day).

Prescription Name / Dosage
(e.g., “mg”) / Frequency (times per day) / Why do you take it?
Over the Counter/
Vitamin/Herbal Name / Dosage / Frequency / Why do you take it?
NAME: DATE:

DIET HISTORY

Current weight: / Weight at 18 years of age:
Lowest weight: / Highest weight:
Height: / Goal (desired) weight:
  1. Record ALL weight loss attempts, especially professionally supervised (physician, and/or registered dietitian) programs.
  1. Start with your first diet and proceed until the most recent one.
  1. If you were on weight-loss medications (e.g., Adipex, Redux, Meridia, Xenical), what type of “food plan” were you following (e.g., 1200-calorie, low-fat, low-carbohydrate, etc) in addition to taking the drug?

Year / Age at start of diet / How long were you on this diet / Weight at start of this diet / Weight lost on this diet / What kind of diet were you on? / Doctor or dietitian who supervised this diet

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