Transcription
Patient Name:WILJON W. BELTRE, M.D., F.A.C.S.CENTER FOR METABOLIC and OBESITY SURGERYToday’s Date:/Month/DayYear-Social Security NumberName:LastFirstMIMaiden NameAddress:StreetCityTelephone: (State)--Zip code( )-HomeBirthdateYour Race:-EmailCell/MonthCountry/DayAge:Sex: M / FYearAsianHispanicAfrican AmericanCaucasianOtherBirthplace:Referred by (circle appropriate option): Self / Family / Friend / Doctor / OtherName (of person making referral):Primary Health Care Provider: Dr.Referring Dr. Phone No.Primary Health Care Dr. Phone No.(())-REQUIREMENT FOR INSURANCE CLAIM FILINGI hereby authorize the physician(s) to release any information acquired in the course of my examination and treatment.Furthermore, I authorize payment directly to the physician(s) of the Medical/Surgical benefits otherwise payable to me forservices as described. A photostatic copy of the authorization shall be considered as valid as the original, and shall bevalid for one year from the date of signature.SIGNATURE OF PATIENT / INSUREDDATEINSURED’S NAME (PLEASE PRINT)1Center For Metabolic and Obesity Surgery Wiljon W. Beltre, M.D., F.A.C.S.
Patient Name:Patients Employer Information:Company Name:Company Address:Company Phone:-Company Fax:-Patient Insurance Information:Company Name:Company Address:Company Phone:-Company Fax:-Policy Number:ID Number:Group NumberI certify that the above insurance information that I have provided is true and correct.SIGNATURE OF PATIENT / INSUREDDATEINSURED’S NAME (PLEASE PRINT)2Center For Metabolic and Obesity Surgery Wiljon W. Beltre, M.D., F.A.C.S.
Patient Name:PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE SO THAT WE CAN GIVEYOU THE BEST POSSIBLE MEDICAL CARE.Briefly state your problem or the reason for your coming to the doctor today.Have you seen any other doctor(s) for this problem?When did you first notice the current problem?Describe the location of your pain / discomfort (if appropriate).Describe your discomfort. (burning, aching, throbbing, pulling, crushing, stabbing, itching, etc.)Does your pain/discomfort radiate or shoot to any other area of your body?Can you mark (circle) the severity of your pain/ discomfort on a scale of 0 to ---10(0 no pain ------------------------------------------10 worst pain ever)How long has this problem been bothering you?How often do you experience this problem (every day/week/month)?Is there anything you can do to make this problem better?Is there anything you can do that you know will cause this problem or make it worse?Is this problem related to any other problems or complaints that you are having?3Center For Metabolic and Obesity Surgery Wiljon W. Beltre, M.D., F.A.C.S.
Patient Name:Past Personal Medical History:Do you have, or have you had in the past, any of the following (circle Yes or No ) ?Yes / No - AsthmaYes / No - PneumoniaYes / No - EmphysemaYes / No - Heart Valve ProblemsYes / No - Heart AttackYes / No - Heart Rhythm ProblemsYes / No - High Blood PressureYes / No - StrokeYes / No - AneurismYes / No - High Cholesterol/TriglyceridesYes / No - DiabetesYes / No - PancreatitisYes / No - Thyroid ProblemsYes / No - Immune system problemsYes / No - Bad HeadachesYes / No - EpilepsyYes / No - JaundiceYes / No - HepatitisYes / No - Stomach UlcersYes / No - Reflux/Heart BurnYes / No - Kidney DiseaseYes / No - CancerYes / No - Excessive BleedingYes / No - AnemiaYes / No -Yes/ No - Clots in the leg veinsExcessive clottingYes/No - Sleep ApneaYes/No - Pulmonary EmbolismYes / No - LeukemiaYes / No - Psychiatric disordersYes / No - ColitisYes / No - DiverticulitisYes / No - ConstipationYes / No - Small bowel inflammationYes/ NoYes / No - Drug dependence- AlcoholismYes / No - ArthritisYes / No - GoutYes / No -Other significant Illnesses (Please List)4Center For Metabolic and Obesity Surgery Wiljon W. Beltre, M.D., F.A.C.S.
Patient Name:Please list any PREVIOUS OPERATIONS:YearType of operationSurgeon1)234)5)6)7)8)9)10)11)HAVE YOU EVER HAD ANY PROBLEMS RELATED TO ANESTHETICS, GENERAL OR LOCAL?If yes please describe:5Center For Metabolic and Obesity Surgery Wiljon W. Beltre, M.D., F.A.C.S.
Patient Name:Current Medications:Please list all medications you are currently using.(Include Aspirin, vitamins, laxatives, contraceptives, herbals and other “over the counter” items)Name of medicineStrength (mg)Number of pillsTimes per day1)2)3)4)5)6)7)8)9)10)11)12)13)14)15)Are there any medications that you are ALLERGIC TO or not able to take? (circle) Yes / NoName of DrugIf Yes:What happens if you take this drug?1)2)3)4)5)6)6Center For Metabolic and Obesity Surgery Wiljon W. Beltre, M.D., F.A.C.S.
Patient Name:FOR WOMEN ONLYMenstrual History (for women only):Age when periods beganDate of last period//Are your periods regular? Yes / NoHow many days apart?ARE YOU OR MIGHT YOU POSSIBLY BE PREGNANT? YESNOHOW MANY TIMES HAVE YOU BEEN PREGNANT?HOW MANY BABIES HAVE YOU HAD?SOCIAL HISTORYYour Highest Level of Education:High SchoolCollegeMarital Status:SingleSeparatedPost graduateMarriedDivorcedHabits:Do you smoke now?Yes/ NoIf Yes:How many packs per day?How many yearsIf No: Did you smoke in the past? Yes / NoHow many packs per day? How many years? Year you quit?Do you drink alcohol now? Yes / NoIf yes: How many drinks per day?How many years?If you are married:Does your spouse smoke now? Yes / NoIf yes:How many per day?How many years?If No:Did they smoke in the past? Yes / NoHow many per day?How many years?Do you drink alcohol now? Yes / NoIf yes:How many per day?Year they quit?How many years?If No:Did you drink alcohol in the past? Yes / NoHow many per day?How many years?7Center For Metabolic and Obesity Surgery Wiljon W. Beltre, M.D., F.A.C.S.
Patient Name:Family History:If LivingAgeCurrent HealthIf DeceasedAge at DeathCause of SisterSex(M/F)AgeCurrent HealthAge at DeathCause of deathChildChildChildChildChildChildChildExtended Family History:Do you know of any blood relatives who have, or have had in the past, anyof the following illnesses? (If Yes, list their relationship to you.)AsthmaHeart ProblemsHigh Blood PressureStrokeDiabetesEpilepsyJaundiceStomach UlcersKidney DiseaseExcessive BleedingColitisAlcoholismCancer (type?)Leukemia8Center For Metabolic and Obesity Surgery Wiljon W. Beltre, M.D., F.A.C.S.
Patient Name:System Review (If you have any questions, ask the physician):General/Constitutional:Yes / No FeverYes / No OtherYes / No FatigueRespiratory:Yes / No Chronic dry coughYes / No WeaknessYes / No Recent weight gain ( amount )Yes / No Recent weight loss ( amount )Yes / No Coughing up bloodYes / No Coughing up mucousYes / No Wake up at night coughing or chokingEyes:Yes / No PainYes / No RednessYes / No Loss of visionYes / No Repeated pneumoniasYes / No WheezingYes / No Night sweatsYes / No OtherYes / No Double or blurred visionYes / No Flashing lights/SpotsYes / No DrynessYes / No Feels like something in eyeYes / No GlassesYes / No OtherEars, Nose, Mouth, Throat:Yes / No Ringing in earsGastrointestinal:Yes / No Decreased appetiteYes / No NauseaYes / No VomitingYes / No Vomiting blood or coffee ground materialYes / No HeartburnYes / No RegurgitationYes / No Frequent belchingYes / No Loss of hearingYes / No Stomach pain relieved by foodYes / No Nose bleedsYes / No Yellow JaundiceYes / No Loss of sense of smellYes / No DiarrheaYes / No Dry sinusesYes / No ConstipationYes / No SinusitisYes / No GasYes / No Post-nasal dripYes / No Blood in stoolsYes / No Sore tongueYes / No Black, tarry stoolsYes / No Bleeding gumsYes / No HemorrhoidsYes / No Sores in the mouthYes / No OtherYes / No Loss of sense of tasteYes / No Dry mouthYes / No Dentures/Removable dental workYes / No Frequent sore throatsYes / No HoarsenessYes / No Constantly feel the need to clear your throatwhen nothing is thereYes / No Wake up with acid or bitter fluid in the mouth or throatYes / No Food sticks in the throat when swallowingYes / No Painful swallowingYes / No OtherCardiovascular:Yes / No Chest painGenitourinary:Yes / No Difficult urinationYes / No Pain or burning with urinationYes / No Blood in the urineYes / No Cloudy or ”smoky” urineYes / No Frequent need to urinateYes / No UrgencyYes / No Needing to urinate frequently at nightYes / No Not able to hold your urineYes / No Discharge from the penis/vaginaYes / No Kidney stonesYes / No Vaginal drynessYes / No Rash or ulcersYes / No Irregular heart beatYes / No Sexual difficultiesYes / No Sudden changes in heart beat (palpitations)Yes / No ImpotenceYes / No Shortness of breathYes / No Prostate troubleYes / No Difficulty in breathing at nightYes / No Sexually transmitted diseasesYes / No Swollen legs or feetYes / No Heart murmursYes / No High blood pressureYes / No Cramping with walkingYes / No Pain in feet or toes at nightYes / No Varicose veinsMusculoskeletal:Yes / No Arm crampsYes / No Buttock crampsYes / No Thigh cramps9Center For Metabolic and Obesity Surgery Wiljon W. Beltre, M.D., F.A.C.S.
Yes / No Calf crampsYes / No Muscle spasmsYes / No Joint/muscle painYes / No Loss of consciousnessYes / No Muscle weaknessYes / No Sensitivity or pain of hands and/or feetYes / No Muscle tendernessYes / No Memory lossYes / No Joint swellingYes / No OtherYes / No Neck painPsychiatric:Yes / No Depression with thoughts of suicideYes / No Back painYes / No InjuriesYes / No Voices in your head telling you to do thingsYes / No OtherSkin and Breasts:Yes / No Easy bruisingYes / No Been seen professionally for psychiatric counseling /treatmentYes / No OtherYes / No Skin rednessEndocrine:Yes / No Can’t tolerate hot or cold temperaturesYes / No Skin rashYes / No HivesYes / No FlushingYes / No Sensitivity to sun exposureYes / No TightnessYes / No Finger nail changesYes / No Increased thirstYes / No Nodules/bumpsYes / No Hair lossYes / No Increased salt intakeYes / No Decreased sexual desireYes / No Color changes in the hands or feet in the coldYes / No OtherYes / No Breast lumpYes / No Breast painYes / No Nipple dischargeYes / No OtherHematologic/Lymphatic:Yes / No AnemiaYes / No Bleeding tendencyYes / No Clotting tendencyNeurological:Yes / No HeadacheYes / No OtherYes / No DizzinessAllergic/Immunologic:Yes / No RhinitisYes / No AsthmaYes / No Skin sensitivityYes / No Latex allergy/sensitivityYes / No OtherYes / No Fainting This section is for physician use only. NOT FOR PATIENT SIGNATUREThe Review of Systems section was reviewed with the patientBy Dr.://DateSignature10
Center for Metabolic & Obesity SurgerySpecializing in Minimally InvasiveWeight Loss Surgery & Advance LaparoscopyWiljon W. Beltre MD, F.A.C.SPlease note that most health insurances that cover obesity surgery will have you complete a medicalweight loss program lasting from four to six months, before they approve the surgery. However, ifyou have completed a weight loss program in the past two years, they may give you credit and youmay not have to wait the time period to get your Surgery approved. Weight Loss programs that youmay get credit for include:1. Weight Loss program through a doctor, nurse or nutritionist2. Jenny Craig3. Weight Watchers4. Transformations5. Nutra SystemHave you done a supervised weight loss program in the last two years? Yes NoDid the weight loss program last for four or more months?Yes NoAre you able to get records?Yes NoName of weight loss program or doctor11
Center for Metabolic & Obesity SurgerySpecializing in Minimally InvasiveWeight Loss Surgery & Advance LaparoscopyWiljon W. Beltre MD, F.A.C.SNotice of Privacy Practice Acknowledgment FormOur notice of Privacy Practices provides information about how we may use and release protected health informationabout you. You have the right to review our notice before signing this form. As provided in our notice, the terms ofour notice may change. If we change our notice, you may obtain a revised copy by writing our practice or requestinga copy from our front desk staff.You have the right to request that we restrict how protected health information about you is used or released fortreatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we arebound by our agreement.By signing this form, you consent to our use and release of protected health information about you for treatment,payment and health care operations as described in our notice. You have the right to revoke this consent, in writing,except where we have already made release on your prior consent.Patient Name:(Print)Patient Signature:Date:Witness:Revisions:Revised date: Patient Received Signature: Date:Revised date: Patient Received Signature: Date:Revised date: Patient Received Signature: Date:Revised date: Patient Received Signature: Date:(Office use only)I attempted to obtain the patient’s signature on this Notice of Privacy Practices Acknowledgment form butwas unable to do so as documented below:Reason:Date:Employee Signature:12
Center for Metabolic & Obesity Surgery Specializing in Minimally Invasive Weight Loss Surgery & Advance Laparoscopy Wiljon W. Beltre MD, F.A.C.S Please note that most health insurances that cover obesity surgery will have you complete a medical weight loss program lasting from four to six months, before they approve the surgery. However, if
