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Magee-Womens Hospital Initial Evaluation Form - UPMC.com

Magee-Womens Hospital Initial Evaluation Form - UPMC.com

Magee-Womens Hospital Initial Evaluation Form -

For Office Use Only____________Date ReceivedDivision of Minimally Invasive Bariatric and General Surgery____________BMIAnita Courcoulas, MDGiselle Hamad, MDCarol McCloskey, MDRamesh Ramanathan, MDINITIAL EVALUATION FORM (Please answer ALL questions before submitting)Name ___________________________________________________ Date of Birth ___________________ Age __________________Address ________________________________________________________________________________________________________City_____________________________________________________ State ____________________ Zip ________________________Home Phone _____________________________________________ Work Phone __________________________________________Preferred Number Home Work Other ______________________________________________________________Social Security No. __________________________________ Email Address _______________________________________________Employment Status: Full-time Part-time Unemployed Place of Employment _______________________________Gender: Male FemaleRace: Caucasian African-American Other ____________________Weight __________Height __________Insurance Type ____________________________________________ Insurance ID# _______________________________________1) How did you hear about our Magee-Womens Hospital bariatric program and/or Information Session? Newspaper Website Radio TV Family/Friend Physician Other________2) How did you receive this Initial Evaluation Form? From attending an Information Session From accessing our official website3) If you accessed this Initial Evaluation Form via our website, did you view the Online Video Session? Yes NoDo you have a preference for a Surgeon? Yes No If so, please name? ____________________________Surgery of interest to you: Gastric bypass Lap-band Other _______________ UndecidedHave you had previous surgery for weight loss? Yes No If yes, what type? _____________________________In your opinion, what contributes to your excess weight? Portion sizes Eating too much fat and sugar Stress eating Emotional eating Compulsive eating Lack of exercise Medications Nervous eating Lack of knowledge about healthful eating/exercisePrimary Care Physician Name _______________________________________ Phone ________________________________Revised 7/2013

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