Microsoft word - seminar packet.doc

PATIENT INFORMATION:
PATIENT NAME: ____________________________________________ DATE OF BIRTH: ___________________________________ AGE: ________________ SS#__________________________________ MARITAL STATUS: M S D W SEX: M F RACE: _____________________________________ PREFFERRED LANGUAGE: __________________________________________ ADDRESS: _____________________________________________________________________________________________________ CITY: ____________________________________________ STATE: ______________ ZIP: ___________________________________ PHONE: HOME________________________________CELL:________________________________WK:________________________ EMAIL: ______________________________________ PLACE OF EMPLOYMENT: ________________________________________ HOW DID YOU HEAR ABOUT US: TV NEWSPAPER BILLBOARD INTERNET FRIEND/FAMILY: __________________________________
OTHER: __________________________________________________________________________________________________________________________________
EMERGENCY CONTACT: _____________________________________________PHONE: ___________________________________ RELATIONSHIP: __________________________________________________________________
REFERRING / FAMILY PHYSICIAN INFORMATION:
REFERRING / FAMILY PHYSICIAN: ________________________________________PHONE:_______________________________ CITY: ____________________________________________________________________ STATE: ______________________________ INSURANCE INFORMATION:
PRIMARY INSURANCE COMPANY:_____________________________________________________________________________
ID #:_________________________________________________________ GROUP #:________________________________________ SUBSCRIBER’S NAME: ___________________________________________SUBSCRIBER’S SS#_____________________________ SUBSCRIBER’S DATE OF BIRTH: __________________________________SUBSCRIBER’S SEX: M F RELATIONSHIP TO PATIENT: _______________ADDRESS:___________________________________CITY______________STATE_______ZIP_____________
SECONDARY INSURANCE COMPANY: _________________________________________________________________________
ID #:_________________________________________________________ GROUP #:_______________________________________ SUBSCRIBER’S NAME: ___________________________________________SUBSCRIBER’S SS#____________________________ SUBSCRIBER’S DATE OF BIRTH: __________________________________SUBSCRIBER’S SEX: M F RELATIONSHIP TO PATIENT: _______________ADDRESS:___________________________________CITY______________STATE_______ZIP_____________
INSURANCE IS NOT GUARANTEED PAYMENT. BALANCE IS DUE WITHIN 90 DAYS OF THE INSURANCE CLAIM UNLESS ARRANGEMENTS
HAVE BEEN MADE THROUGH OUR OFFICE.
FINANCIAL AGREEMENT
“THE INFORMATION STATED ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE. I, THE PERSON RESPONSIBLE FOR PAYMENT OF MEDICAL CARE FOR THE ABOVE PATIENT, AGREE TO PAY FOR THE OFFICE VISIT AND SERVICES THE DAY THE CARE IS PROVIDED. I AGREE TO PAY ANY BALANCE DUE ON OTHER CHARGES WITHIN 90 DAYS FROM THE DATE THAT SERVICE IS PROVIDED”. SIGNATURE: _________________________________________________________________ DATE: _________________________________________
OWLO2007/Reception/seminar packet 10/2011 BARIATRIC MEDICAL QUESTIONNAIRE

DATE TODAY: __________________________
___________________________________________________________________________________________________________________________________________
LAST NAME
FIRST NAME
BIRTHDATE

MARITAL STATUS: M S W D
OCCUPATION:
_____________________________________________________________________________________________________________________________
PRIMARY HEALTH CARE PROVIDER (PLEASE LIST THE LAST 5 YEARS) OK
__________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ OWLO2007/Reception/seminar packet 10/2011 WEIGHT LOSS ATTEMPTS
PERSONAL HISTORY
Please Circle all that apply
FAMILY HISTORY
Please SPECIFY which family member has the below co-morbidities:
Include (Grandparents, Parents, Siblings, and Children) Diabetes_________________________________________________
Depression___________________________________________________
High Blood Pressure_______________________________________
Bleeding Disorder_____________________________________________
Heart Attack(s) ___________________________________________
Psychiatric illness_____________________________________________
Stroke___________________________________________________
Cancer – If so, what kind(s)? ____________________________________
Obesity__________________________________________________
_____________________________________________________________
High Cholesterol__________________________________________
OWLO2007/Reception/seminar packet 10/2011 I HAVE/HAVE NOT had previous WEIGHT LOSS SURGERY.
Date of Previous Weight Loss Surgery: __________________________________________________________________________________
Surgeon/Address:
__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Type of Procedure:
Gastric Bypass (Roux-en-Y), Laparoscopic
Original Weight _________________ Lowest Weight Achieved______________________
Were there any Complications:
If so, explain _________________________________________________________________________________________________
_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ SURGICAL HISTORY
Please CIRCLE and LIST date
_________________Colon/Intestinal Surgery OWLO2007/Reception/seminar packet 10/2011 HEALTH HISTORY

CARDIOVASCULAR DISEASE
( ) Diagnosis of hypertension, no medication PULMONARY
( ) Symptoms with more than ordinary activity ( ) Sleep apnea symptoms (Negative sleep study) ( ) Sleep apnea diagnosis by sleep study (no CPAP) ( ) Sleep apnea with significant hypoxia or Oxygen ( ) No history of ischemic heart disease ( ) History of MI or anti-ischemic medication ( ) No Symptoms of obesity hypoventilation ( ) Right heart failure-Left ventricular dysfunction ( ) Anginal chest pain only with extreme exertion ( ) No symptoms or indication of pulmonary hypertension ( ) Anginal chest pain with minimal exertion ( ) Well controlled on anticoagulants and/or ( ) Previous heart attack by history or by ( ) Patient needs or has had a lung transplant ( ) No symptoms of peripheral vascular disease ( ) Claudication, anti-ischemic medication ( ) Transient ischemic attack, rest pain ( ) Intermittent mild symptoms, no medication ( ) Procedure for peripheral vascular disease ( ) Symptoms controlled with oral inhaler ( ) Stroke, loss of tissue secondary to ischemia ( ) Well controlled with ongoing daily medication ( ) symptoms not well controlled, steroids ( ) No symptoms of lower extremity edema ( ) Hospitalized within last 2 years, history of intubation GASTROINTESTINAL
( ) Disability, decreased function, hospitalization ( ) Intermittent or variable symptoms, no medication ( ) History of DVT resolved with anticoagulation ( ) Meet criteria for anti-reflux surgery, or prior ( ) Recurrent DVT long term anticoagulation meds ( ) Recurrent PE, decreased function, hospitalization METABOLIC
( ) Diabetes, controlled with oral medication ( ) Modestly enlarged liver, Normal Liver function ( ) Modestly enlarged liver, Abnormal Liver function ( ) Diabetes, controlled with insulin and oral ( ) Liver failure, transplant indicated or done (retinopathy, neuropathy, renal failure) OWLO2007/Reception/seminar packet 10/2011 MUSCULOSKELETAL
( ) No history of stress urinary incontinence ( ) Intermittent symptoms not requiring treatment ( ) Symptoms requiring non-narcotic treatment ( ) Degenerative changes or positive objective findings ( ) Surgical intervention done or recommended ( ) Failed previous surgical intervention with ( ) Asymptomatic hernia, no prior operation ( ) symptomatic hernia with or without incarceration ( ) No symptoms of musculoskeletal disease ( ) Surgical intervention required (ex: arthroscopy) ( ) Awaiting or past joint replacement or ( ) Able to walk 200 ft with assistance device ( ) Cannot walk 200 ft with assistance device ( ) Treatment with non-narcotic medications ( ) Treatment with narcotics: Surgical intervention ( ) Pannus so large it interferes with ambulation REPRODUCTIVE
PSYCHOSOCIAL
( ) Mild and episodic not requiring treatment ( ) Moderate, accompanied by some impairment, ( ) Moderate with significant impairment, ( ) Moderate with significant impairment ( ) Severe, definitely requiring intensive Substance Abuse (Prescription or Illegal Drugs) ____________pack per day times___________years OWLO2007/Reception/seminar packet 10/2011 MEDICATIONS
Include prescribed and non-prescription medicines, vitamins, “Natural remedies”, aspirin, Tylenol, cold meds, etc.
NAME__________________________________________________Date of Birth______________________

ALLERGIES:
REACTION TYPE 1 (Minor rash or nausea)
2 (Severe rash or vomiting)
3 (Difficulty breathing or shock)
Name of Medication
Reaction Type
Name of Medication
Reaction Type
___________________ ______________ ____________________ ___________________ ______________ ____________________

MEDICATIONS currently taking
Name of Medication Strength How Often Taken
______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ ______________________________ __________ _______________ PLEASE CHECK for ACCURACY ONE MORE TIME!!!!!!!!!!
THANK YOU!!!!!!!!!!!!!!!!!
OWLO2007/Reception/seminar packet 10/2011 IT HAS BEEN PROVEN THAT 1 IN EVERY 3
AMERICANS SUFFER FROM A SLEEP DISORDER
Complete the following quiz and score yourself at the bottom.
( ) 1. I have been told that I snore
( ) 2. I have been told that I stop breathing while I sleep
( ) 3. I have gained weight
( ) 4. I suffer from high blood pressure
( ) 5. I feel fatigued during the day
( ) 6. I suffer from morning headaches
( ) 7. I have lost interest in sex
( ) 8. I sweat excessively during the night
( ) 9. I suddenly wake up unable to breathe
( ) 10. My family and friends say that they have noticed a change in my personality
( ) 11. I have been told that I kick in my sleep
( ) 12. I experience a “creepy, crawly” sensation in my legs
( ) 13. I have excessive daytime drowsiness
( ) 14. I have been told that I am a restless sleeper
( ) 15. I awaken with sore or achy muscles
( ) 16. I often have trouble staying asleep throughout the night
( ) 17. I have fallen asleep while driving
( ) 18. I experience vivid nightmares soon after falling asleep
( ) 19. No matter how hard I try to stay awake, I fall asleep
( ) 20. I fall asleep throughout the day
( ) 21. I feel paralyzed when I am waking up or falling asleep
( ) 22. I feel like I am hallucinating when I fall asleep
( ) 23. I feel afraid to go to sleep
( ) 24. I have trouble falling asleep
( ) 25. Thoughts run through my mind, preventing me from going to sleep
( ) 26. It often takes me an hour or more before I fall asleep
( ) 27. I wake up in the middle of the night unable to return to sleep
Sleep Apnea is a life threatening sleep disorder which frequently causes you to stop breathing. It can happen
hundreds of times per night while you sleep and you may not even be aware it is happening.

Place the number checked from each of the following sections in the space provided below.
__________ Questions 1-10
__________ Questions 11-16
__________ Questions 17-22
__________ Questions 23-27
OWLO2007/Reception/seminar packet 10/2011 OWLO PATIENT EMAIL CONSENT
Patient Name: _________________________
f) Provider is not liable for breaches of Patient Address: _______________________
confidentiality caused by the patient or any third Email: _______________________________
g) It is the patient’s responsibility to follow up and/or schedule an appointment if warranted. 1. RISK OF USING EMAIL
Transmitting patient information by email has a number of 3. INSTRUCTIONS
risks that patients should consider before using email. To communicate by email, the patient shall: These include, but are not limited to, the following: a) Avoid use of his/her employer’s computer. a) Email can be circulated, forwarded, stored b) Put the patient’s name in the body in the body electronically and on paper, and broadcast to unintended c) Key in the topic (e.g., medical question, billing b) Email senders can easily misaddress an email. c) Backup copies of email may exist even after the sender d) Inform Provider of changes in his/her email of the recipient has deleted his or her copy. d) Employers and on-line services have the right to e) Acknowledge any email received from the inspect email transmitted through their systems. e) Email can be intercepted, altered, forwarded, or used f) Take precautions to preserve the confidentiality f) Email can be used to introduce viruses into computer 4.PATIENT ACKNOWLEDGEMENT AND
g) Email can be used as evidence in court. AGREEMENT
h) Emails may not be secure and therefore it is possible I acknowledge that I have read and fully that the confidentiality of such communications may be understand this consent form. I understand the risks associated with the communication of email between the Providers and me, and consent to the 2. CONDITIONS FOR THE USE OF MAIL
conditions and instructions outlined, as well as any Providers cannot guarantee but will use reasonable other instructions that the Provider may impose to means to maintain security and confidentiality of email communicate with patients by email. If I have any information sent and received. Providers are not liable for questions I may inquire with my treating physician improper disclosure of confidential information that is not caused by Provider’s intentional misconduct. Patients must acknowledge and consent to the following conditions: a) Email is not appropriate for urgent or emergency situations. Provider cannot guarantee that any particular Email will be read and responded to within any particular b) Email must be concise. The patient should schedule an appointment if the issue is too complex or sensitive to Patient Signature: ______________________
c) All email will be printed and filed in the patient’s Date: _________________________________
d) Office staff may receive and read your messages. e) The patient should not use email for communication regarding sensitive medical information. OWLO2007/Reception/seminar packet 10/2011 Ronnie Keith D.O
CONSENT FOR USE & DISCLOSURE OF HEALTH
INFORMATION

SECTION A: PATIENT GIVING CONSENT
Name: _________________________________________________________________________________________________ Address: _______________________________________________________________________________________________ Telephone: ______________________________________ E-mail: ________________________________________________ Social Security Number: ___________________________ Date of Birth: ___________________________________________ SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.

Purpose of Consent: by signing this form, you will consent to our use and disclosure of your protected health information to carry
out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this
consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and
disclosures we may make of your protected health information, and of other important matters about your protected health
information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing
this consent.
We reserve the right to change our Privacy Practices as described in our Notice of Privacy Practices. If we change our privacy
practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of
your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting our office.
Telephone: (405) 360-7100 Fax: (405) 364-9112
Address: 3400 West Tecumseh Road Suite 205, Norman, Oklahoma 73071
Right to revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted
to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance
on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke
this Consent.
My information may be released to the following organizations and/or individuals:
___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
SIGNATURE SECTION – PLEASE PRINT
I, ________________________________________, have had full opportunity to read and consider the consents of this Consent
form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and
disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.
Signature: _________________________________________________________ Date: __________________________ If this Consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative’s Name: __________________________________________________________________________ Relationship to Patient: ___________________________________________________________________________________ OWLO2007/Reception/seminar packet 10/2011

Source: http://www.owlo.com/0p/PatientPacket_110611.pdf