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Allina Health Weight Management - Kids and Teens ProgramWelcome! Thank you for choosing Allina Health Weight Management. The Kids and Teens programhas many weight loss options, and we will work with you to find the right one for you.Please complete the health history form so the team can be ready to work with your family onthe day of your appointment.Kids and Teens Weight Management Program The Kids and Teens program is a resource for kids, teens, and young adults to achieve ahealthier weight. Families and patients work with a team of doctors, dietitians, mental healthproviders, physical therapists and other specialists. Family involvement is important. Parent support of changes in the home environment areimportant for improved weight and health of the child. We welcome parents, caregivers andsiblings to come to clinic visits. The first clinic visit takes time. You can expect to be in clinic for 3 to 4 hours. During that time,families will meet with the doctor, dietitian, psychologist, physical therapist and nurse. Pleasenote: If it is easier for your family to space these appointments out, please let us know. We arehappy to schedule appointments to meet the needs of your family.During the first visit you can expect: Doctor – the doctor will complete a medical evaluation and create an individualtreatment plan. The treatment plan will include visits with the psychologist, and possibly,referrals to other medical specialists. Dietitian – the dietitian will look at current eating habits and overall nutrition to create ameal plan that supports child and family goals. Physical therapist – the physical therapist will look at current level of activity andmovement to see if excess weight has had an effect on the child’s growth anddevelopment. The therapist will recommend a safe and effective plan for physicalactivity.Surgeon – in some adolescent patients, after 6 to12 months of intensive, medicallysupervised weight management efforts, the team, patient and family may determinethat they are more appropriately treated with an operation. A consultation may berecommended with the bariatric surgeon.For additional support in talking with your child about weight and health: www.weighinonobesity.orgWeight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 1 of 15PATIENT LABEL
INSURANCE VERIFICATION FORMKids and Teens ProgramYou must contact your insurance company to determine your coverage for weight loss services. To do so,please call the customer service number on the back of your insurance card. Keep record of the date of yourcall as well as the name of the customer service representative who provided you the information.Your Name:Date of Birth:Have you had weight loss surgery in the past?// Yes NoINSURANCE INFORMATIONPrimary Insurance:Company:/ID#Group# /ID#Group# Secondary Insurance (If applicable):Company:If UCARE Insurance, what is the PMI number: Are you the subscriber: Yes NoIf not, Name of Subscriber, Date of Birth, and Relationship/ /Social Security Number of Subscriber: (Tricare and Veterans Insurance ONLY)Provider Phone Number OR Customer Service Phone Number on the back of yourinsurance card:We will document the information we receive in your Excellian Chart. This will be provided to your nurseclinician prior to your Initial Visit so that she can accurately determine a plan of care for you to meet yourspecific insurance criteria. If we determine that you DO NOT have insurance coverage for weight lossservices, we will contact you. Please provide the best phone number to reach you and also indicate if we areable to leave a message for you at that phone number.Be aware that Medicare and Medicare replacement plans do not coverdietitian visits. Medicare enrollees may be asked to sign a waiveracknowledging these visits may not be a covered service. InitialsFor Office Use Only:Location:ANWProvider: Phone: Okay to Leave a Message: Yes NoWeight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 2 of 15PATIENT LABELDate of Visit: STFUTDUTY
Stop BangInsOffice Use Only:Date Rcvd: MRN: Approval: EE: PKG: Appts: IDEA: Excellian: Doc Type: QuestionnaireDescriptor: BariatricKids, Teens and Young AdultsHealth History FormDate:Please bring the records from your most recent doctor visit with you when you come to yourWeight Management appointment.Patient’s Name:Date of Birth:Address:City:Age: State:Zip Code: Parent / Legal Guardian: Person Completing Form:Relationship to Patient: Emergency Contact:Phone Number:Email: What is the patient’s preferred language?What is the caregiver’s preferred language? Would you like the clinic to provide an interpreter?9 Yes9 NoWeight HistoryCurrent height?Current weight?BMI / Percentile (This will be calculated by staff)At what age did the patient first become overweight?Average weight over the past 5 yearsPattern or known causes of weight gain?9 Since infancy9 Gradual over time9 Postpartum9 Depression or other significant life eventDescribe: 9 Medication related. Name of medication(s): 9 Sudden / unexpectedExplain: 9 Other: Weight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 3 of 15PATIENT LABEL
Weight Loss HistoryWeight Loss Attempts – Indicate which diet programs tried in the pastDiet ProgramAtkins dietDatesPounds lostCabbage soupCalorie countingDiabetic dietExerciseGrapefruitJenny CraigLA Weight LossLow fat / low cholesterolPhysician supervised programMedifastNew DayNutrisystemOther high protein / low carbohydrateOptifastOvereaters AnonymousOwn reduced calorie / portionsRegistered Dietitian visitsSlimfastSlimgenicsSouth BeachTOPSWeight WatchersZoneOtherWeight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 4 of 15PATIENT LABEL
Weight Loss Medications – Indicate which medications the patient has used to lose weightMedicationDatesPounds lostlorcaserin (Belviq)metformin (Glucophage)naltrexone HCL/Buproprion HCL (Contrave)orlistat (Alli, Xenical)phenterminephentermine / topiramate (Qsymia)sibutramine (Meridia)topiramate (Topamax or Trolandi)bupropion (Wellbutrin)liraglutide (Saxenda)Other:Has the patient tried diet and exercise for a period of at least 6 months?Has the patient tried diet and exercise for a period of at least 3 months?YesNoDid you lose 1 pound or more a week while trying diet and exercise?Dietary AssessmentWhat time do you:Wake up?Eat breakfast?Eat lunch?Eat dinner?Eat snacks?Go to bed?Dietary recall:How many meals does the patient eat each day?How many times does the patient snack each day?How many cups of fruit does the patient eat each day?How many cups of vegetables does the patient eat each day?Describe what the patient typically eats for each of the following:BreakfastLunchDinnerSnacksNutritional HistoryWhat are the patient’s nutrition and health goals?Is there anything that holds the patient back fromattaining his or her health and nutrition goals?What, if anything has the patient tried in the pastto manage his or her nutrition related concerns?Weight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 5 of 15PATIENT LABELDo not include corn and potatoes
Food PreferencesIs the patient following a special diet? Does 9 Yes 9 No Please explain:he or she have specific dietary limitationsor needs based on health, ethnic, cultural,or religious preferences?Pleaselist:Food AllergiesSensitivitiesWhich dietary choices or habits do youfeel the patient is most challenged by?Who is involved in preparing food forand feeding the patient?9 Self9 ParentIntolerances9 SchoolFood Cravings9 DaycareFood Dislikes9 In-Home Care9 GrandparentWho does the food shopping for your household?Where is food shopping done?Dining Out History:How many times does the patient eat out each week?Where does the patient eat out?What foods does the patient order when eating out?Describe what the patient typically consumes for liquids:TypeAmount in ouncesAlcoholDiet sodaRegular sodaMilkJuiceWaterArtificially sweetened waterOtherCoffee9 caffeine 9 decafSugarHow much:CreamHow much:Tea9 caffeine 9 decafSugarHow much:CreamHow much:Meal Activity:How long does it take the patient to eat a meal?How often does the patient skip meals?When at home, where does the patient eat mealsand snacks?Weight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 6 of 15PATIENT LABELper dayper weekper month
YesNoCommentDoes the patient do any binge eating?Does the patient eat until uncomfortably full?Does the patient eat when not physically hungry?Does the patient or caregiver worry that they haveloss of control over how much eaten?Does the patient wake at night to eat?Physical ActivityIndicate past exercise efforts:9 group exercise classes9 use of a pedometer / fitness tracker9 personal trainerDescribe current exercise program:Type of exerciseFrequency (number of days per week)Duration (number of minutes per session)If not exercising, what keeps the patientfrom exercising?Ability to Walk:9 no limitations9 Use of a braceAble to walk 2 blocks?Able to go up and down a flight of stairs?How often?9 health club membership (YMCA, Curves, SNAP Fitness, etc.)9 home exercise (videos, treadmill, etc.)9 other – describe:9 Use of a cane9 Yes 9 No9 Yes 9 No9 Use of a walkerAllergiesList allergies to medicine, food, dye, tape, metal, latex.Allergy9 Use of a WheelchairReactionMedicationsList all current medications including vitamins, over-the-counter medications, supplements, andintermittently used medications (or attach a current list).NameDoseHow often takenPurposeYear startedPharmacy of Choice – name the pharmacy used to have prescriptions filled.Name of pharmacyCity/LocationWeight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 7 of 15PATIENT LABELPhone Number
Pregnancy/Birth HistoryAt what week in the pregnancy was the patient born?During pregnancy, did the patient’s birth mother have: Gestational Diabetes? 9 YesHigh Blood Pressure? 9 YesWere there any other problems during the pregnancy? 9 Yes 9 No Explain:Were there any problems during the delivery?9 Yes 9 No Explain:9 Vaginal Delivery9 C-SectionWere there any special problems soon after the birth? 9 Yes 9 No Explain:Normal State Newborn Screen9 Yes 9 No Explain:Birth WeightBreast Fed?9 Yes 9 No How long?9 No9 NoMedical HistoryHas the patient every been diagnosed with any of the following:CardiovascularRespiratoryMusculoskeletal irregular heart beat asthma rheumatoid arthritis heart block obstructive sleep apnea d egenerative disc disease(DDD) pacemaker/palpitations pulmonary hypertension chest pain (angina) emphysema/COPD degenerative joint disease(DJD) / osteoarthritis heart disease congestive heart failure heart attack (MI) high blood pressure coronary artery disease carotid artery disease edema high triglycerides h igh LDL cholesterolor low HDL pulmonary embolismLiver/Stomach/Intestine gallstones inflamed gallbladder hepatitis ulcer h. pylori colitis spastic colon irritable bowel Crohn disease h eart murmur /abnormal heart valve acid reflux or heartburn(GERD) p ass out orlose consciousness fatty liver(NASH or NAFLD) blood clot or DVT increased LFT’sKidneys / Genitourinary Infectious Diseases renal insufficiency VRE diabetic kidney disease MDRO kidney failure MRSA currently on dialysis C Diff stress incontinence HIV positiveSkin kidney stones problems with healingof wounds/cuts/bruiseswhere: herniated disc gout carpel tunnel syndrome plantar fasciitis Scoliosis Slipped capitalfemoral epiphysis Blant diseaseNeurological seizures migraines neuropathy/nerve pain sciatica pseudotumor cerebri narcolepsy/drop attacks paralysis restless leg syndrome fibromyalgia multiple sclerosis stroke/CVA Charcot Marie ToothSyndromeWeight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 8 of 15PATIENT LABELObesity? 9 Yes 9 NoEndocrine diabetes type I diabetes type II pre-diabetic diabetic eye problems impaired fasting glucose diabetic ulcers low thyroid (hypothyroid) infertility hypoglycemia metabolic syndrome morbid obesity obesity pancreatitisReproductive/Male penile deformity cryptorchidismOther awaiting organ transplant –type: glaucoma: open angle glaucoma: narrow angle glaucoma: unknown other eye problem history of cancer genetic disorder developmental delay learning disability
Mental HealthHas the patient ever been diagnosed with:YesNoDate of ty / Panic attacksSchizophreniaPsychosisPersonality disorderCompulsive overeatingAnorexia NervosaBinge eating disorderBulimiaOther / describeCheck all that apply:YesNoCommentThoughts of self harm (now or in the past)Past suicide attemptProvider name:Under the care of a psychiatristDuration of treatment:Provider name:Under the care of a counselor or therapistDuration of treatment:Has the patient taken anti-depressants, anti-psychotics, stimulants or ADHD medication before?Name of MedicinePrescribed byMonth/Year TakenConditionWeight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 9 of 15Dosage and Length of TreatmentPATIENT LABEL
Has the patient had any of the following?tests/evaluations:EKG?echocardiogram? (ultrasound of heart)YesDateName of facilityor health systemResult/Explanationstress test?other heart tests?sleep study (or screening for sleep apnea)upper endoscopy procedure(s) (EGD)?colonoscopy?thyroid test?Hgb A1c?EEG/qEEGTreatment?Female ReproductiveAge at time of first period?After the first year, menstrual periods have been (check all that apply) Regular, periods every weeks Irregular Normal flow Not applicable, explainYesDoes the patient use birth control? Heavy flow/many clotsNoWhat method?Is there a possibility the patient is pregnant?Has the patient ever been pregnant?If yes, explain:Does the patient have polycystic ovariansyndrome (PCOS)?Any breastfeeding in the past six months?Dental ProblemsYesDoes the patient have dentures or partials?Ever been diagnosed with TMJ?Does the patient have trouble chewing?Does the patient have trouble swallowing liquids, pills or solids?Had wisdom teeth removed?Have missing teeth?When was the patient’s last dental visit?Date:Weight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 10 of 15PATIENT LABELNo
Surgical HistorySurgeryYearIncision locationYesNoReasonCommentHas the patient had problems with anesthesia?Has the patient ever had a blood transfusion?When:Weight Loss Surgery – complete this section ONLY if the patient has had weight loss surgery before.CommentsWhat year was weight loss surgery?Name of surgeon:Where:( months postop)Weight before surgery:Lowest weight after surgery:Any adverse events after surgery?Describe:Indicate type of operation: gastric bypass (Roux-en-Y) adjustable gastric band (Lap-band or Realize band) duodenal switch vertical banded gastroplasty (VBG) sleeve gastrectomy Other:Family HistoryAgenowor atdeathCause ofdeathCancer –(includetype)CoronaryArteryDisease –typeand ageof onsetDiabetesType?I, ternalGrandPaPaternalGrandMaPaternalGrandPaWeight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 11 of 15PATIENT LABELHighbloodpressureObesityBMI 30 or 95%childrenBleedingorClottingDisorder(specify)
Review of SystemsCheck off any symptoms the patient currently has:GeneralCardiac fatigue chest pain fevers fast heart rate chills irregular heart rate insomnia lightheadedness e xcessive daytime fainting or passing outsleepiness or drowsiness none of the aboveGastrointestinal none of the aboveHead and Neck heartburn TMJ Symptoms constipation recent dental problems diarrhea none of the above IBS SymptomsEyes lactose intolerance change in vision wheat intolerance eye pain hemorrhoids none of the above stool incontinenceRespiratory abdominal pain shortness of breath at rest Nausea/vomiting shortness of breath none of the abovewith activityPsychological cough excessive worry snoring anxiety waking up due to snoring panic attacksor stopping breathing depression none of the above feeling “up” or elated none of the aboveMusculoskeletal low back pain neck pain muscle pain joint pain – location: muscle or joint stiffness mobility problems use of cane or walker none of the aboveSkin acne recurrent skin infections skin tags stretch marks dark skin onneck or armpits(acanthosis nigricans) none of the aboveVascular swelling oflower extremities ulcers oflower extremities none of the aboveMale Genital/Urinary incontinence blood in urine difficult urination impotence erectile dysfunction none of the aboveFemale Genital/Urinary stress incontinence menstrual irregularity heavy menses blood in urine excessive facial hair none of the aboveNeurological seizures tremors headaches migraine headaches tension headaches balance problems walking problems nerve pain numbness/tingling none of the aboveSleep Apnea ScreenHas the patient been screened, diagnosed, or treated for sleep apnea? 9 Yes 9 NoDetails: Average hours of sleep per nightDoes the patient have current bedwetting? 9 Yes 9 NoCollar size of shirt: 9 S 9 M 9 L 9 XL or inches cmYesSnoring - Does the patient snore loudly (louder than talking or loud enough to be heard through closed doors?)Tired - Does the patient often feel tired, fatigued, or sleepy during the day?Observed - Has anyone observed the patient to stop breathing during sleep?Blood Pressure - Is the patient being treated for high blood pressure?BMI - BMI more than 35 kg/m2Age - Age over 50 years old?Neck circumference - Neck circumference greater than 40 cm/15.75 inchesGender - Gender male?Weight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 12 of 15PATIENT LABELNoX
Social HistoryDoes the patient attend daycare?9 Yes 9 NoDoes the patient attend preschool?9 Yes 9 NoDoes the patient attend school?9 Yes 9 NoIs the patient in a relationship?9 Male 9 Female 9 Both9 Kindergarten 9 1st9 7th 9 8th 9 9th9 Yes 9 No9 2nd 9 3rd 9 4th 9 5th 9 6th9 10th 9 11th 9 12th 9 CollegeAs a caregiver how do you learn best? 9 Reading9 Listening 9 DemonstrationIf yes, please specify:As a caregiver do you have any learning9 Yes 9 Nodifficulties or barriers to learning?9 PicturesHow does the patient learn best?9 Pictures9 Reading9 Listening 9 DemonstrationIf yes, please specify:9 Yes 9 NoDoes that patient have any learningdifficulties or barriers to learning?The patient typically goes to bed at:The patient typically wakes at:The patient typically gets hours of sleep per nightComments:The patient’s favorite activities are:ActivityThe patient is involvedActivityin the followingexercise activities orActivitysportsAverage screen time per day minutes/hoursIs the patient employed? 9 Yes 9 Duration:(Check one) 9 television9 computer9 smartphoneDescribe Amount/FrequencyYesNoType/Amount/FrequencyDoes the patient currently use tobacco?Is the patient exposed to tobacco?Does the patient consume alcohol?Has the patient ever used street drugs?Is the patient exposed to street drugs?YesNoType / TreatmentDoes the patient have a history of chemical dependency?Is there a family history of chemical dependency treatment?Weight Management - Kids and TeensProgram Health History Form*59-01*9 video gameSR-17044 (08/17)Page 13 of 15When:PATIENT LABEL
Readiness to ChangeThis exercise will help you understand how ready the patient is to change certain behaviors related to health and wellbeing. The answers will help your team determine what areas of health are most important, as well as help set realisticgoals. Please do not judge team answers, just try to be as truthful as possible. There are no right or wrong answers.In the first column, rank on a scale of 1-10 how important the following behaviors are to you (1 not importantat all and 10 very important). If the behavior is not applicable (i.e. you do not smoke), just write “NA” in the box.Keep in mind; something can be important to us, even if we struggle to change the behaviors. If you think aboutsomething often, chances are it is important to you.In the second column, rank on a scale of 1 – 10 how confident you are that you can make and maintain changes inthese areas (1 not confident at all and 10 very confident/already part of my lifestyle).BEHAVIORIMPORTANCECONFIDENCEReduce / cease smokingWeight managementPhysical activityNutritionStress managementMedication complianceSleep1 not important1 not confident10 very important10 very confidentNA not applicableWeight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 14 of 15PATIENT LABEL
Medical Care ProvidersList all current care providers, starting with primary care provider. Include the area of specialty, addresses, and phonenumbers, conditions treated, and length of time seeing this provider:Primary Care Provider Name:Clinic: Address:Phone: Specialty: Family Medicine Internal Medicine Pediatrics Other: (check one)How long with this provider?Provider Name:Clinic: Address: Specialty:Phone: Conditions TreatedHow long w/provider? Provider Name:Clinic: Address: Specialty:Phone: Conditions TreatedHow long w/provider? Provider Name:Clinic: Address: Specialty:Phone: Conditions TreatedHow long w/provider? Did a medical provider refer you to our program? Yes NoIf yes, who referred you? Weight Management - Kids and TeensProgram Health History Form*59-01*SR-17044 (08/17)Page 15 of 15PATIENT LABEL
Weight Management - Kids and Teens Program Health History Form PATIENT LABEL SR-17044 (08/17) 59-01 Page 1 of 15 Allina Health Weight Management - Kids and Teens Program Welcome! Thank you for choosing Allina Health Weight Management. The Kids and Teens program has many weight loss options, and we will work with you to find the right one for you.
