Mini-Gastric Bypass Patient Information Form

Please fill in the information on this form to allow Dr. Rutledge to begin your evaluation for the Mini-Gastric Bypass.
Send it to Dr. Rutledge by clicking the send button at the bottom of this form.
* Click Here for Tips, Help and Advice on Filling out this Form.  
* Please, use good Grammar and Punctuation (DO NOT USE ALL CAPS.) 
* Please, Take your time, fill in the form VERY carefully. 
* Please, use full and complete sentences. 
* Please, spell carefully and use correct capitalization. 
* Please, Don't be sloppy. Do not rush.
Patient Identification Information:
DateAdded:
File Name:
Middle Name:
How did you hear about us?  
Birthdate:
Age (years):
Gender:
Race Ethnicity:
Occupation:
Employer:
Employer's Address:
Employer's Phone:
Insurance Company Name:
Insurance Company Address:
Insurance Company City:
Insurance Company State:
Insurance Company Zip code:
Insurance Account Number:
Insurance Account Name:
Insurance Account Type ID:
Insurance Account Description:
Your Weight Now: lbs.
Your Waist (inches): inches
Height (ft., in.): feet   inches
Have You Tried Diets: (Yes?)
Diet History:
Diet History Description:
Tried Exercise:
Exercise Description:
Tried Support Groups:
Support Group Description:
Tried Counseling:
Counseling Description:
Have You Tried Medications:
     Dexfenfluramine (Redux):
     Fenfluramine (Pondimin):
     Fenfluramine and phentermine (fen-phen):
     Meridia (Sibutramine):
     Xenical (Orlistat):
Describe your experience with medications for weight loss:
Do you have Depression: Do you have depression?
Depression Description:
Does obesity interfere with your daily activities? Yes (Click Here if obesity interferes with your daily tasks)
     Walking:
     Dressing:
     Climbing Stairs:
     Work:
     Play/Recreation:
     Tie Shoes:
     House work:
     Standing:
     Getting out of a chair:
     Child Care:
     Sitting:
     Sexual Relations:
     Picking up things:
     Shopping:
     Exercise:
     Bathing:
     Cleaning Self:
Daily Tasks Description:
Do you have Diabetes:
Diabetes Description:
Do you have Shortness of Breath:
Do you have Sleep Apnea:
Sleep Apnea Description:
Do you have Lung Disease:
Lung Description (Asthma, Sleep Apnea, COPD, etc.):
Do you have Thyroid Disease:
Thyroid Description:
Do you have High Blood Pressure:
High Blood Pressure Description:
Do you have Heart Disease:
Do you have Angina:
Have you had an MI (Heart Attack):
Do you have Dyspnea on Exertion (Shortness of breath):
Do you have CHF (Heart Failure):
Do you have Pedal Edema (Ankle Swelling):
Heart Disease Description:
Do you have High Cholesterol:
     Cholesterol Level:
     Triglyceride Level:
High Cholesterol Description:
Do you have Incontinence (involuntary loss of urine):
Incontinence Description:
Do you have Gallbladder disease:
Gallbladder Disease Bladder Description:
Do you have Arthritis:
Arthritis Description:
Please Discribe Any Gastrointestinal Diseases:  
Do you have any GI Disease:
      Peptic Ulcer:
      Gastro-Esophageal Reflux:
      Hiatal Hernia:
      UGI Bleed:
      Lower GI Bleed:
      Dysphagia (Problems Swallowing):
      Nausea Vomiting:
      Liver Disease:
      Diarrhea or Constipation:
      Hemorrhoids:
      Abdominal Pain:
     Pancreas Disease:
     Description of any GI Disease:
Questions for Women:  
Do you have any form of Gynecologic Disease:
Gynecologic Illness Description:
when was your last menstrual period:
Do you have an form of Renal or Kidney Disease:
Renal or Kidney Disease Description:
Please describe any prior history of surgery (Description):
Have you had prior weight loss surgery:
Type of Weight Loss Surgery:
Date of Weight Loss Surgery:
Description of previous weight loss surgery:
Please list in detail all of your Medications:
Do you have a Penicillin (or Cephalosporin) Allergy:
Description of Penicillin Allergy:
Describe your Drug Allergies:
Do you use Alcohol (Y/N):   (Click Here if you drink alcohol)
Describe Your Alcohol Use:
Are you a Smoker? (Click Here if you are a smoker)
Family History  
Family History of Obesity:
Description of your Family History Obesity :
Family History of Medical Diseases:
Family History Diabetes: (Yes, Click here)
Family History Heart Disease: (Yes, Click here)
Family History Stroke: (Yes, Click here)
Family History Hypertension: (Yes, Click here)
Family History of Cancer: (Yes, Click here)
Family History Medical Disease Description:
Your Referring Physician's Full Name:
Referring Physician Address:
Ref Physician City:
Ref Physician State:
Ref Physician Zipcode:
Ref Physician phone:
Ref Physician Fax:
Social History, Describe you history of smoking, alcohol, drug use or pain medications (Warning it is very important to know if you use alcohol, drugs, narcotic pain medication or anti-anxiety medications like Klonopin ):