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Allina Health Weight Management (Allina Health)

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Allina Health Weight Management
Thank you for choosing Allina Health Weight Management. The Weight Management Program off ers comprehensive
weight loss options for patients of all ages. Please review the following descriptions to assure we get you scheduled with
the right program and providers.
Kids, Teens and Young Adults Weight Management Program - serving ages 25 and younger
The Kids, Teens and Young Adult program is a resource to achieve a healthier weight. Individuals and families
work with medical doctors, dietitians, nurse practitioners, mental health providers, physical therapists, surgeons,
and other specialists. If you are interested in the program, please complete a diff erent intake form for that
program. It can be found at AllinaHealth.org/kidswm.
Medical Weight Management Program
Individual Program – The individual program is a personalized, one-on-one non-surgical program. Patients
meet with a weight loss physician or nurse practitioner to create a specialized treatment plan. A registered
dietitian will develop a diet tailored to your specifi c needs. The focus is on portion control, healthy eating, and
a moderately reduced calorie diet that will work for you. This plan may include medications. The individual
program cost for provider and dietitian visits is covered by most insurers, with the exception of Medicare and
Medicare replacement plans.
Allina Health Weight Management off ers a cash pay option for dietitian visits for Medicare and Medicare
replacement plan patients.
Optifast Meal Replacement Program
The Optifast program is a medically supervised complete meal replacement program. Patients are seen by a
nurse practitioner or physician assistant during the active weight loss phase. Lifestyle and behavior change
are key to success. The Optifast program includes weekly classes and visits with our registered dietitian. The
weekly classes are taught by healthcare professionals (Registered Dietitian, Exercise Physiologist, Nurse
Practitioner and Physician Assistant). Classes are 45 to 60 minutes in length and are not mandatory, but are
highly encouraged as those who attend group sessions for weight management lose more weight.
Surgical Weight
Management Program
The surgical program off ers the sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal switch operations.
Your decision to have weight loss surgery is personal and complex. The Surgical Weight Management team
of surgeons, physician assistants, nurse practitioners, psychologists, nurses, dietitians, and support staff will
provide support, assistance, and advice throughout your journey before and after weight loss surgery.
Please remember that with any clinic visit, co-pays,
coinsurance and deductibles may apply.
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
SR-16301 (01/21)
*59-01*
Please complete form using blue or black ink
Indicate which Weight Management Program you would like to enroll in. Refer to cover letter on page 1 for a
description of the programs. Select only one option.
Kids, Teens and Young Adult Program: this is a non-surgical and surgical program serving ages 25 and younger.
Please use separate health history form located at allinahealth.org/kidswm or call 763-236-0940 for a copy.
Optifast Medical Program: this is the Optifast Meal Replacement Program that includes food products for purchase
Bloomington
Coon Rapids
Vadnais Heights
Woodbury
Medical Program: this is the non-surgical program that may include medications
Bloomington
Brooklyn Park
Coon Rapids
United
Vadnais Heights
Woodbury
Surgical Program: this is for weight loss surgery
Abbott Northwestern
Mercy
St. Francis
United
Name: Date of Birth: Age:
Address: City: State: Zip Code:
Phone Number: Email:
Weight History
What is your current height? What is your current weight?
BMI (this will be calculated by staff )
How long have you been this weight? Years:
At what age did you fi rst become overweight?
Lowest adult weight Highest adult weight (non-pregnant)
Average weight over the past 5 years
Stop Bang Doc Type: Questionnaire
Descriptor: Bariatric
Offi ce Use Only:
Date Rcvd:
MRN:
Approval:
EE:
Appts:
Excellian:
Ins:
Allina Health Weight Management
Health History Form
Page 1 of 14
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Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
*59-01*
SR-16301 (01/21)
Medical History
Cardiovascular Respiratory Musculoskeletal Endocrine
irregular heart beat asthma osteoarthritis diabetes type I
heart block obstructive sleep apnea rheumatoid arthritis diabetes type II
pacemaker/palpitations pulmonary hypertension degenerative disc disease
(DDD)
glucose intolerance /
pre-diabetic
chest pain (angina) emphysema/COPD degenerative joint
disease (DJD) where:
diabetic eye problems
heart disease pulmonary embolism herniated disc diabetic ulcers
congestive heart failure
Liver/Stomach/Intestine
gout low thyroid (hypothyroid)
heart attack (MI) gallstones carpal tunnel syndrome infertility
high blood pressure infl amed gallbladder plantar fasciitis hypoglycemia
coronary artery disease hepatitis joint pain metabolic syndrome
carotid artery disease ulcer swelling morbid obesity
edema h. pylori pain obesity
high triglycerides colitis stiff ness pancreatitis
high cholesterol or
low HDL
spastic colon
Neurological Reproductive/Male
irritable bowel seizures prostate cancer
heart murmur /
abnormal heart valve
Crohn’s disease migraines impotence
acid refl ux or heartburn neuropathy/nerve pain penile deformity
pass out or
lose consciousness
fatty liver
(NASH or NAFLD)
sciatica penile prosthetic device
erectile dysfunction
blood clot or DVT increased LFT’s pseudo tumor cerebri enlarged prostate
Kidneys / Genitourinary
Cirrhosis narcolepsy/
drop attacks
urinary symptoms due to
enlarged prostate
renal insuffi ciency pancreatitis paralysis
Other
diabetic kidney disease trouble swallowing restless legs awaiting organ transplant
– type:
kidney failure
Infectious Diseases
fi bromyalgia glaucoma: open angle
currently on dialysis VRE multiple sclerosis glaucoma: narrow angle
stress incontinence MDRO stroke/CVA glaucoma: unknown
kidney stones MRSA Charcot Marie Tooth
Syndrome
other eye problem
Skin
C Diff history of cancer
problems with healing
of wounds/cuts/bruises
HIV positive
Page 2 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
SR-16301 (01/21)
*59-01*
Review of Systems
Check off any symptoms you currently have:
General Cardiac Musculoskeletal Male Genital/Urinary
fatigue chest pain low back pain incontinence
fevers fast heart rate neck pain blood in urine
chills irregular heart rate muscle pain diffi cult urination
insomnia lightheadedness fi bromyalgia up at night to urinate
excessive daytime
sleepiness or drowsiness
fainting or passing out
joint pain – location:
impotence
none of the above erectile dysfunction
none of the above
Gastrointestinal
muscle or joint stiff ness none of the above
Head and Neck
heartburn mobility problems
Female Genital/Urinary
TMJ constipation use of cane or walker stress incontinence
recent dental problems diarrhea none of the above menstrual irregularity
none of the above IBS
Skin
heavy menses
Eyes
lactose intolerance acne blood in urine
change in vision wheat intolerance recurrent skin infections excessive facial hair
eye pain hemorrhoids skin tags none of the above
none of the above stool incontinence stretch marks
Neurological
Respiratory
abdominal pain none of the above seizures
shortness of breath at rest
Nausea/vomiting
Vascular
tremors
shortness of breath with
activity
none of the above swelling of lower
extremities
headaches
Psychological
migraines
cough excessive worry
ulcers of lower
extremities
tension headaches
snoring anxiety balance problems
waking up due to snoring
or stopping breathing
panic attacks none of the above walking problems
depression nerve pain
none of the above feeling “up” or elated numbness/tingling
none of the above none of the above
STOP BANG
If you have already been diagnosed with sleep apnea and have been prescribed a CPAP or BiPAP,
you do NOT have to complete this section.
Collar size of shirt
S M L XL or _____ inches cm
Neck circumference _______ inches / cm (This will be measured by staff )
Yes No
Snoring – Do you snore loudly (louder than talking or loud enough to be heard through closed doors?
Tired – Do you often feel tired, fatigued, or sleepy during the day?
Observed – Has anyone observed you stop breathing during your sleep?
Blood Pressure – Do you have or are you being treated for high blood pressure?
BMI – BMI more than 35 kg/m
2
?
Age – Age over 50 years old?
Neck circumference – Neck circumference greater than 40 cm / 15.75 inches?
Gender – Gender male?
Page 3 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
*59-01*
SR-16301 (01/21)
Surgical History
List all previous surgeries
Surgery Year Incision location Reason
Yes No Comment
Have you had problems with anesthesia?
Weight Loss Surgery – complete this section ONLY if you have had weight loss surgery before
Comments
What year did you have weight loss surgery?
Name of surgeon Where:
Weight before surgery Lowest weight after surgery
Any adverse events after surgery? Describe:
Indicate which operation you had
gastric bypass (Roux-en-Y) adjustable gastric band (Lap-band or Realize band)
duodenal switch vertical banded gastroplasty (VBG)
sleeve gastrectomy Other:
Page 4 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
SR-16301 (01/21)
*59-01*
Family History
Age now
or at
death
Cause of
death
Cancer –
Colon
Coronary
Artery
Disease –
type and
age of
onset
Diabetes
High
cholesterol
High
blood
pressure
Obesity
Bleeding
or
Clotting
Disorder
Stroke
Mother
Father
Sister
Brother
Maternal
GrandMa
Maternal
GrandPa
Paternal
GrandMa
Paternal
GrandPa
Is there a family history of: Yes No Family member
Substance Abuse Dependence
Depression
Anxiety
Severe mental illness
Page 5 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
*59-01*
SR-16301 (01/21)
Substance Use
Yes No Type/Amount/Frequency
Do you currently use tobacco?
Have you ever used tobacco?
How many years did you use?
How much did you use? Packs per day:
When did you quit?
Yes No Type/Amount/Frequency
Do you consume alcohol?
Last consumed alcohol? When:
Yes No Type/Amount/Frequency
Have you ever used an illicit drug such as
marijuana, cocaine, meth, or heroin?
Last use? When:
Yes No Type/Amount/Frequency
History of chemical dependency?
History of chemical dependency treatment? When:
Social History
Yes No Comment
Are you presently in a relationship? If yes, for how long?
Do you have children? What are their ages?
Are you currently employed?
If yes, how long have you been employed?
Occupation:
Are you disabled?
Reason:
Work status:
Are you sexually active? If so, male or female partner?
Do you use birth control? What method?
Female Reproductive
Yes No Comment
Is there a possibility that you are pregnant?
Are you planning future pregnancies?
Are you currently breast feeding?
Have you gone through menopause?
Do you have a history of polycystic ovarian
syndrome (PCOS)?
Menstrual periods – check all that apply
Regular Irregular Heavy fl ow/many clots
Normal fl ow Peri-menopausal Not applicable
What is the date that your last pregnancy was complete /
date of delivery?
Date:
Page 6 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
SR-16301 (01/21)
*59-01*
Allergies
List allergies to medicine, food, dye, tape, metal, latex.
Allergy Reaction
Medications
List all current medications you are taking including vitamins, over-the-counter medications, supplements, and
intermittently used medications.
Name Dose How often taken Purpose Year started
Pharmacy of Choice – name the pharmacy you use to have your prescriptions fi lled.
Name of pharmacy City/Location Phone Number
Physical Activity
Indicate past exercise eff orts:
group exercise classes health club membership (YMCA, Curves, SNAP Fitness, etc.)
use of a pedometer home exercise (videos, treadmill, etc.)
personal trainer other – describe:
Describe current exercise program:
Type of exercise
Frequency (number of days per week)
Duration (number of minutes per session)
If not exercising, what keeps you from exercising?
Ability to Walk:
no limitations Use of a brace Use of a cane Use of a walker Use of a Wheelchair
Are you able to walk 2 blocks?
Yes No
Are you able to go up and down a fl ight of stairs?
Yes No
Page 7 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
*59-01*
SR-16301 (01/21)
Have you ever been diagnosed with:
Yes No Date of diagnosis Treatment
Depression
Bipolar
Anxiety / Panic attacks
Schizophrenia
Psychosis
Personality disorder
Compulsive overeating
Anorexia Nervosa
Binge eating disorder
Bulimia
Other / describe
Check all that apply:
Yes No Comment
Thoughts of self harm
Past suicide attempt
Under the care of a psychiatrist
Under the care of a counselor or therapist
Have you ever been prescribed:
Yes No Date stopped
MAO inhibitor
tranylcypromine (Parnate)
phenelzine (Nardil)
selegiline (Eldepryl, Emsam, Zelapar)
Page 8 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
SR-16301 (01/21)
*59-01*
Weight Loss History
Weight Loss Attempts – Indicate which diet programs you have tried in the past
Diet Program Dates Pounds lost
Atkins diet
Cabbage soup
Calorie counting
Diabetic diet
Exercise
Grapefruit
Jenny Craig
LA Weight Loss
Low fat / low cholesterol
MD supervised program
Medifast
New Day
Nutrisystem
Other high protein / low carbohydrate
Optifast
Overeaters Anonymous
Own reduced calorie / portions
Registered Dietitian visits
Slimfast
Slimgenics
South Beach
TOPS
Weight Watchers
Zone
Other
Do you have a pattern or known causes of weight gain?
Gradual over time
Postpartum
Depression or other signifi cant life event Describe: _________________________________________________
Medication related. Name of medication: _________________________________________________________
Sudden / unexpected Explain: _______________________________________________________________
Other: _____________________________________________________________________________________
Page 9 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
*59-01*
SR-16301 (01/21)
Weight Loss Medications – Indicate which medications you have used to lose weight
Medication Dates Pounds lost
lorcaserin (Belviq)
metformin (Glucophage)
naltrexone HCL/Buproprion HCL (Contrave)
orlistat (Alli, Xenical)
phentermine
phentermine / topiramate(Qsymia)
sibutramine (Meridia)
topiramate (Topamax or Trolandi)
wellbutrin
Other
Fen-phen
Redux (dexfenfl uramine)
Yes No
Did you take Fen-phen or Redux for longer than 3 months?
If yes, did you have an echocardiogram?
Yes No
Have you tried diet and exercise for a period of at least 3 months?
Have you tried diet and exercise for a period of at least 6 months?
Did you lose 1 pound or more a week while trying diet and exercise?
Dietary Assessment
What time do you:
Dietary recall:
Wake up?
How many meals do you eat each day?
Eat breakfast?
How many times do you snack each day?
Eat lunch?
How many cups of fruit do you eat each day?
Eat dinner?
How many cups of vegetables do you eat each day? Do not include corn and potatoes
Eat snacks?
Go to bed?
Describe what you typically eat for each of the following:
Breakfast
Lunch
Dinner
Snacks
Page 10 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
SR-16301 (01/21)
*59-01*
Dining Out History:
How many times do you eat out each week?
Where do you dine out?
What foods do you order when you dine out?
Describe what you typically consume for liquids:
Type Amount in ounces per day per week per month
Alcohol
Diet soda
Regular soda
Milk
Juice
Water
Artifi cially sweetened water
Other
Coff ee caff eine decaf
Sugar How much:
Cream How much:
Tea caff eine decaf
Sugar How much:
Cream How much:
Meal Activity:
How long does it take you to eat a meal?
How often do you skip meals?
Who does the grocery shopping?
Who prepares the meals in your home?
Describe your family dynamics
around food (as a child and currently)
Yes No Comment
Do you do any binge eating?
Do you eat until uncomfortably full? How often?
Do you eat when not physically hungry?
Do you worry that you have loss of control over
how much you eat?
Do you wake at night to eat?
Page 11 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
*59-01*
SR-16301 (01/21)
PROMIS v.1.2 - Global Health
Global Health
Please respond to each question or statement by marking one box per row.
Excellent
Very
Good Good Fair Poor
Global01
In general, would you say your health is: ...............................
5
4
3
2
1
Global02
In general, would you say your quality of life is: ...................
5
4
3
2
1
Global03
In general, how would you rate your physical health? ...........
5
4
3
2
1
Global04
In general, how would you rate your mental health, including
your mood and your ability to think? ......................................
5
4
3
2
1
Global05
In general, how would you rate your satisfaction with your
social activities and relationships? ..........................................
5
4
3
2
1
Global09
In general, please rate how well you carry out your usual
social activities and roles. (This includes activities at home,
at work and in your community, and responsibilities as a
parent, child, spouse, employee, friend, etc.) ..........................
5
4
3
2
1
Completely Mostly Moderately A Little Not at All
Global06
To what extent are you able to carry out your everyday
physical activities such as walking, climbing stairs, carrying
groceries, or moving a chair? ..................................................
5
4
3
2
1
In the past 7 days... Never Rarely Sometimes Often Always
Global10
How often have you been bothered by emotional problems
such as feeling anxious, depressed or irritable? ......................
5
4
3
2
1
None Mild Moderate Severe
Very
Severe
Global08
How would you rate your fatigue on average? .......................
5
4
3
2
1
Global07
How would you rate your pain
on average? ...............................
          
0 1 2 3 4 5 6 7 8 9 10
No Worst
pain pain
imaginable
22 August 2016
© 2010-2016 PROMIS Health Organization and PROMIS Cooperative Group
Page 12 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
SR-16301 (01/21)
*59-01*
Medical Care Providers
List all providers you receive care from, starting with your primary care provider. Include their area of specialty,
addresses, and phone numbers.
Primary Care Provider: Clinic:
Address: Phone:
Referring Provider Name: Clinic:
Address:
Specialty: Phone:
Mental Health Provider Name: Clinic:
Address:
Specialty: Phone:
Appointment Policy
We try to provide the best service possible to the clients we serve. To allow us to do this, it is important
that you come for all of your scheduled appointments. If you need to cancel or reschedule, please
contact our offi ce at least 24 hours in advance. This allows us the opportunity to off er that appointment
time to another patient who is waiting.
If you have three cancellations without 24 hours’ notice or three no shows in one year, program services
may be terminated. The Program Manager or Nurse Clinician will attempt to contact you to assess your
ongoing interest and commitment to the program.
If you need to cancel or reschedule an appointment please contact the clinic where your appointment is
scheduled.
Page 13 of 14
Allina Health Weight Management
Program Health History Form
PATIENT LABEL
Patient Name:
Patient Date of Birth: / /
*59-01*
SR-16301 (01/21)
SURGICAL PROGRAM
INSURANCE VERIFICATION FORM
Only complete this form if you are interested in weight loss surgery.
Medicare Patients: Be aware that Medicare and Medicare replacement plans do not cover dietitian visits. Medicare
enrollees may be asked to sign a waiver acknowledging these visits may not be a covered service. The cost for the
dietitian component of the program will be at least $620.00
Patient Initials
You must contact your insurance company to determine your coverage for weight loss services To do so, please call the
customer service number on the back of your insurance card. Keep record of the date of your call as well as the name
of the customer service representative who provided you the information.
If you are enrolling in the Surgical Program, we will contact your insurance carrier as well to verify your coverage and
criteria for weight loss surgery. This is to ensure that all information provided to you and to us is accurate. In order to
do this on your behalf, please complete the following:
Your Name: Date of Birth: / /
Have you had weight loss surgery in the past? Yes No
INSURANCE INFORMATION
Primary Insurance:
Company: /ID# Group#
Secondary Insurance (If applicable):
Company: /ID# Group#
If UCARE Insurance, what is the PMI number:
Are you the subscriber: Yes No
If not, Name of Subscriber, Date of Birth, and Relationship
_________________________________________________ /________________ /___________________
Social Security Number of Subscriber: ____________________ (Tricare and Veterans Insurance ONLY)
Provider Phone Number OR Customer Service Phone Number on the back of your insurance card:
We will document the information we receive in your Excellian Chart. This will be provided to your nurse clinician
prior to your Initial Visit so that she can accurately determine a plan of care for you
to meet your specifi c insurance criteria. If we determine that you DO NOT have
insurance coverage for weight loss surgery, we will contact you. Please provide
the best phone number to reach you and also indicate if we are able to leave a
message for you at that phone number.
Phone: ____________________ Okay to Leave a Message: Yes No
For Offi ce Use Only:
Location: ANW MCY STF UTD
Provider:
Date of Visit:
Page 14 of 14
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