Atlanta General and Bariatric Surgery Center

Available Forms

Copy of Patient Satisfaction Survey Copy of Patient Satisfaction Survey General Surgery Post Operative Instructions Patient Satisfaction Survey PRE-ASSESSMENT QUESTIONNAIRE Weight Loss Surgery Discharge Instructions

PRE-ASSESSMENT QUESTIONNAIRE

Thank you for choosing Atlanta General and Bariatric Surgery Center for your upcoming surgery. Please fill out the following about your health to the best of your knowledge. This information allows us to develop a anesthesia plan that is specific to your health needs. Once you submit this form a member of our clinical staff will call you to verify information and answer any questions you may have. If you have any questions regarding your procedure and would like to speak directly with one of our nurses, please call us at (678) 691-6257. Please try to complete this form no less than 3 days before your surgery.

Basic Information

Patient First Name *

Patient Last Name *

Date of Birth *

Last four digits of your social security number *

Please put your last four digits of your social security number here. We use this for verification purposes only.

Phone number where we can best reach you *

Planned surgical procedure *

Date of Surgery *

Who will accompany you to the Surgery Center?

Name *

Please make certain they are available to remain in the facility for your entire visit. If your driver leaves the facility, your procedure may be delayed or cancelled.

Do you have an advanced directive or living will?

Yes

If you have a living will or advanced directive, please bring a copy with you to add to your chart

Would you like more information on getting an advanced directive?

(Check here and we will provide information on your surgery day.)

Do you have any special communication needs?

None

I need an interpreter

I have hearing aids

I have impaired vision

Do you have any mobility limitations?

None

Cane/Walker

Wheelchair

Do you have any

Dentures/Bridges

Braces/Retainers

Caps/Crowns

Chipped/Broken/Loose teeth

Glasses/Contacts

False eyelashes

Wig/Hairpiece

Hearing aids

Piercings that cannot be removed

I have none of the above

Allergies

Allergies to medication, food, latex, or other *

Please tell us about your allergies. If you do not have any allergies please list "none"

Tell us about your previous anesthesia experience

This is my first time having anesthesia

I have had anesthesia before without any problems

I have had anesthesia before and had problems

I have family members that had problems with anesthesia

List your past surgeries

If you have never had surgery, please list "none"

Please list any anesthesia problems you have experienced

Please list what kind of problems your family members had with anesthesia

For Females Only

Date of your last menstrual period

I am of child bearing age and could be pregnant

We will give you a pregnancy test on admission to the surgery center.

There is no possibility I could be pregnant

Medications

I take herbal supplements

Some herbal supplements can have adverse interactions with your anesthetic.

I take weight loss medication(s)

Some weight loss medications can have adverse interactions with anesthetic.

Please list all medications including prescription, over-the-counter, herbal or dietary supplements that you take including dosages

List the name of the drug, dosage, and how many times a day you take it.

Health History

Height *

Weight *

Do you have or have you had: (Check all that apply)

Cardiovascular

None

Heart disease (including heart murmur, pacemaker, internal defibrillator, catheterization, stents, heart surgery, irregular heart beat, or mitral valve prolapse)

Chest Pain

Previous EKG, Stress Test, and/or Echocardiogram

High Blood Pressure

Other

Specify any heart problems

Specify any cardiac tests you have had in the last 6 months

Respiratory

None

Lung Disease (Lung Cancer, COPD, and/or Chronic Bronchitis)

Abnormal Chest X-Ray

Asthma

Chronic Cough

Shortness of Breath

Sleep Apnea

Use of CPAP/BIPAP

List your CPAP Setting here

Specify lung problems

Gastrointestinal

None

Bowel/Colon disease or problems

Frequent heartburn/indigestion/esophageal reflux, hiatal hernia

Specify gastrointestinal problems

Liver and Genitourinary

None

Kidney Disease

Difficulty Voiding

Prostate Problem

Dialysis

Liver Disease/Hepatitis/Jaundice

Specify liver and genitourinary problems

Endocrine

None

Thyroid or goiter problems

Diabetes

Do you take insulin?

Please tell us how much insulin you take (i.e. units, when you take it)

If you are diabetic, what was your last blood sugar?

Specify Endocrine problems

Neurological

None

Epilepsy/Seizures/Stroke/Neurological Problems

Other

Specify any neurological problems

Autoimmune

None

Steroid Use

Autoimmune disorders/connective tissue disorders/lupus/sarcoid

Specify autoimmune disorder

Nutrition and Exercise

Are you on a special diet?

Specify Diet

Do you exercise regularly?

Recent Weight Loss within last six months?

Tell us how much weight you have lost

Psychological

None

Psychological Conditions (Depression, anxiety, bipolar disorder, schizophrenia, etc.)

Specify psychological conditions here.

Eye Problems

None

Other

Cataracts

Glaucoma

If you have glaucoma, do you use drops?

Specify eye problems

Musculoskeletal

None

Arthritis

Metal or prosthesis implanted

If yes, where?

Back or Neck Problems

Muscle Weakness

Fibromyalgia

Broken bones in face, back, or neck

Other

Specify musculoskeletal problems

Communicable Diseases and Blood Transfusion history

None

Past/Present Carrier of a infectious disease

Exposure to communicable disease in the past 3 weeks

Bleeding or clotting abnormalities

Nose Surgery

History of Blood Transfusions

If yes, when did you last have a blood transfusion?

Specify any communicable disease or blood transfusion

Social History

Do you use tobacco products?

If you smoke, how many packs per day?

If you smoke, for how long?

If you quit smoking, how long ago?

Do you use recreational drugs?

The following best describes my alcohol consumption

Is there anything else you would like us to know?

List any other medical problems we should know about

List any other information you want us to know

Important Pre-op instructions

Do not eat or drink anything after midnight prior to your surgery. If you are currently taking heart, blood pressure of thyroid medications, you should take these with a small sip of water as you normally would the morning of surgery. If your blood pressure medication is lisinopril or an ACE Inhibitor (usually ends in "pril") do not take this medication the day of surgery. Diabetic patients: DO NOT TAKE YOUR INSULIN the day of your surgery. Consult with your primary physician prior to surgery to determine if you should take your oral medications. Aspirin and NSAIDS contribute to bleeding. These should be stopped a week prior to your surgery. If you are taking aspirin or blood thinners, consult your physician before you stop taking these types of medications. If you use a CPAP machine, please bring it with you on the day of surgery. You cannot wear jewelry in the operating room, please leave all valuables at home. Dress comfortably. Remember to bring your insurance and ID card. If you have any other questions- do not hesitate to call us! (678) 691-6257.

I have provided my health information to the best of my knowledge and understand the Pre-op instructions above. I understand that if I have questions I may call (678) 691-6257 to speak directly with a clinical provider.

* Required field