|
Referred by
|
|
|
Age
|
Sex
|
|
Co-morbidities
• • •
|
Co-morbidities
|
|
Info for weight loss surgery
• • •
|
|
|
Weight loss attempts
• • •
|
Other weight loss attempts
|
|
Onset of obesity
|
|
|
Surgical History
|
Bariatric Surgery
• • •
|
|
Other Surgey
• • •
|
Any other surgery
|
|
Occupation/student
|
Tobacco
|
|
Alcohol
|
Drugs
|
|
Marital status
|
Living arrangements
|
|
Constitutional
|
Constitutional
• • •
|
|
Cardiovascular
|
Cardiovascular
• • •
|
|
Respiratory
|
Respiratory
• • •
|
|
Gastrointestinal
|
Gastrointestinal
• • •
|
|
Genitourinary
|
Genitourinary
• • •
|
|
Neurologic
|
Neurologic
• • •
|
|
Skin
|
Skin
• • •
|
|
Hemorrhage
|
Hemorrhage
• • •
|
|
Hematological
|
Hematological
• • •
|
|
Psychiatric
|
Psychiatric
• • •
|
|
Musculoskeletal
|
Musculoskeletal
• • •
|
|
Eyes/Ears
|
Eyes/Ears
• • •
|
|
|
|
|
Family History
|
|
|
Mother
|
Disease
• • •
|
|
Father
|
Disease
• • •
|
|
Siblings
|
Disease
• • •
|
|
Children
|
Disease
• • •
|
|
Other Relatives
|
Disease
• • •
|
|
|
|
|
General WNL
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Skin WNL
|
Skin Lesion
|
|
Skin Comments
|
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Neck Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
MSK Comments
|
|
|
Breasts WNL
|
Breasts Abnormal
• • •
|
|
Breasts Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Extrem Comments
|
|
|
|
|
|
Assessment/Summary
|
|
|
Age
|
Sex
|
|
BMI
|
Disease
• • •
|
|
Surgery
• • •
|
|
|
Bariatric work up
• • •
|
Comments
|
