BMI of Texas 9910 Huebner Rd, Suite #250 San Antonio TX 78240 Phone (210)615-8500 Fax (210)615-8501 New Bariatric Surgery Patient Intake Questionnaire
In order to minimize your wait time and maximize your experience at BMI of Texas, please take a moment to complete this questionnaire. We realize this is a lengthy form but assure you it is all important information and will be kept confidential. Please Print
First Name: ________________________Last Name: _______________________DOB:_________________
Preferred Surgeon (circle one): Michael Seger, MD
Desired Procedure: First Choice Chief Complaints: CONTINUE TO NEXT PAGE Staff Use Only:
Advocate: ______________________________________ Surgeon: ____________________________ Appointment Date: ___________________________________ Time: __________________________
Adipose Relate Comorbities
Date of onset: ________________ Taking Rx? ________________
Date of onset: ________________ Taking Rx? ________________
Date of onset: ________________ Taking Rx? ________________
Date of onset: ________________ Taking Rx? ________________
Date of onset: ________________ Taking Rx? ________________
Date of onset: ________________ Taking Rx? ________________
Date of onset: ________________ Taking Rx? ________________
Date of onset: ________________ Taking Rx? ________________
Renal Insufficiency Date of onset: ________________ Taking Rx? ________________
Date of onset: ________________ Taking Rx? ________________
Date of onset: ________________ Taking Rx? ________________
Weight History
How many years have you been at your current weight? ______________
How many years have you been obese? ___________
How many years have you been more than 35 pounds overweight? __________
How many years have you been more than 100lbs overweight? _________
At what age did you start to diet? _______________
What is your maximum weight you’ve reached? ________________
What was your most significant amount of weight loss? _____________
How long was this loss sustained? ________________________________________________________
What was your method of weight loss? ____________________________________________________
Do you consider yourself to be: (circle all that apply)
Volume Eater -- Sweet Eater -- Snacker/Grazer -- Emotional Eater -- Binge Eater
Please indicate which unsupervised diets you have tried in the past: Please indicate which supervised diets you have tried in the past: Please indicate which weight loss medications you have tried in the past: Please indicate which methods of exercise you have previously tried to lose weight.
Please indicate if you have utilized any of the following to assist with your weight loss attempts:
Medical History
Please carefully review the list of medical conditions/problems listed below and check any that apply
Autoimmune Psychosocial Gynecological Neurological Infectious Disease Musculoskeletal Gastrointestinal Abdominal Hematological Pulmonary Endocrine No medical History Surgical History:
Please list non-bariatric surgeries (surgeries not related to weight loss) you have had or indicate if you have not had
No prior non-bariatric surgeries Example: Open Hysterectomy w/ ovaries removed, 1/25/99, no complications Procedure/Surgery: specify laparoscopic/Open Date:
Please list previous bariatric (weight loss) surgeries:
No prior bariatric surgeries Procedure/Surgery: (laparoscopic/Open)Date: Original Weight: Lowest Weight Complications: Medications: Please list below any and all medications/vitamins you are currently taking.
Example: Lipitor 10mg one tablet daily at bedtime
1.____________________________________________________________________________________
2.____________________________________________________________________________________
3.____________________________________________________________________________________
4.____________________________________________________________________________________
5.____________________________________________________________________________________
6.____________________________________________________________________________________
7.____________________________________________________________________________________
8.____________________________________________________________________________________
9.____________________________________________________________________________________
10. ____________________________________________________________________________________
Allergies: Do you have allergies to any of the following:
Medications, if so, please list medication and reaction: __________________
_______________________________________________________________
_______________________________________________________________
Iodine, when: ____________________________________________________
IV Contrast, when: ________________________________________________
Adhesives, type: _________________________________________________
Disability:
Are you currently considered to be disabled by the U.S. Social Security Administration?
If yes, for what reason are you disabled? Year of disability: ________________
Disability due to recent disabling illness
Disability due to chronic medical condition: (describe)__________________________
Do you utilize a wheelchair or motorized scooter?
If yes, how long have you required this assistance? __________________________________
Family History: (Please include only parents, grandparents, and siblings) __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ _________________________________ __________________________________ Social History:
If yes, How many packs per day? _______________
For past smokers
How many years ago did you quit smoking? ____________
How many years did you smoke? ______________
How many packs a day did you smoke? _________________
If yes, how many times/week? __________________________
Do you currently use illicit/street drugs? No Rarely
If yes, what type did/do you use and how often? _________________________________________
*Note to patient: We apologize for the length of this form but we feel that all of this information is
very important to enable our office and staff to provide you with excellent care.
Review of Systems
Neurologic Respiratory Psychosocial Endocrine/Metabolic Head and Neck Constitutional Hematological Cardiovasuclar Gastrointestinal
Are you planning more children? ________
Musculoskeletal Dermatological Gynecological
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BMI of Texas 
Abdominal 
Medications: Please list below any and all medications/vitamins you are currently taking. 
Do you utilize a wheelchair or motorized scooter?
If yes, how long have you required this assistance? __________________________________
Family History: (Please include only parents, grandparents, and siblings)