Examination yes
Lower extremity edema
Upper extremity edema
Varicose veins
Observable deformities
Visible wounds
Comorbidities yes
Hypertension
Diabetes
CHF
Asthma
History of thromboembolism
Sleep apnea
Ischemic heart disease
Stroke
Angina
Cardiac surgery
Psychiatric disease
Liver Disease
Osteoarthritis
Discopathy
Other
yes Ischemic heart status
History of MI
Abnormal ECG
PCI, CABG
Drug treatment for IHD
yes Stroke status
Sensory
Motor
Verbal disturbance
Cognitive and memory loss
yes Stroke status
OCD
Anxiety disorder
Depression
Other
yes Endoscopy
Barrett’s esophagus
Hiatal hernia
H-Pylori infection
Peptic ulcer disease
GERD
yes Endoscopy
Para esophageal hernia
Hiatal hernia
Ulcer
yes Endoscopy
Normal sinus rhythm
Atrial Fib
Sinus tachycardia
Other arrhythmias
ST-T wave changes/Possible ischemia
Other (specify)
yes health insurance
Heart disease
Pulmonary disease
Liver disease
Digestive disease
Psychiatric disease
Drug allergy
Uncontrolled chronic disease (specify)
History of gastric cancer in first-degree relatives
History of abdominal surgery
History of surgical complication/DVT
Other (specify)
YesNo
YesNo
YesNo
yes Surgery type Date
RYGB
BPD
BPD-DS
AGB
Gastric balloon
VBG
SG
History of surgery on alimentary tract for other reasons
Other
YesNo
YesNo
YesNo
yes Drug Value Method
Iron
Folate
Calcium
Vit D
Vit B12
YesNo
YesNo
yes pain location days/week
Low back pain
Knee pain
Pelvic pain
Ankle pain
YesNo
YesNo
YesNo
yes Drug Form Count Desc.
Anti-diabetic agents
Antihypertensive drugs
Lipid-lowering agents
Corticosteroids
Cardiac drugs
Neurologic/Psychiatric medication
Anti-arthritic/Discopathy drugs
Thyroid drugs
Antiasthma/Apnea drugs
Liver disease medications
Other (specify)
yes Drugs Value
Metformin
Glibenclamide
Gliclazide
Glitazone
Acarbose
Other oral agents
yes Drugs Value
Insulin Regular
Insulin NPH
Insulin Glargine (Lantus)
Insulin Aspart (Novorapid)
yes Drugs Value
Triamterene H
Hydrochlorothiazide
Spironolactone
Furosemide
Atenolol
Metoprolol/Propranolol
Carvedilol
Metoral
Prazosin/ terazosin
Verapamil
Diltiazem
Nifedipine
Amlodipine
Captopril/ Enalapril/ lisinopril
Losartan/ Valsartan
Other oral antihypertensives
yes Drugs Value
Furosemide
Other parenteral anti-hypertensive
yes Drugs Value
Clofibrate/Simfibrate
Gemfibrozil
Cholestyramine/ Calcitriol
Colestipol
Nicotinic acid
Niacin
Atorvastatin/ Lovastatin
Fluvastatin/ Simvastatin
Ezetimibe
Other
yes Drugs Value
Hydrocortisone
Prednisolone
Betamethasone
Dexamethasone
yes Drugs Value
Hydrocortisone
Prednisolone
Methyl prednisolone
Betamethasone
Dexamethasone
Triamcinolone
Test Result Not performed
Hemoglobin
Hematocrit
Total White Count
Platelet
Fasting Glucose
Hemoglobin A1C
Triglycerides
HDL
LDL
Total Cholesterol
SGOT
SGPT
Alkaline Phosphatase
Test Result Not performed
Urine assessments (24-Hr)
Albumin
24-hr urine protein
Creatinine
Albumin to Creatinine ratio (%)
UFC 24hr (urine free cortisol)
Blood assessments
Hemoglobin
Hematocrit
Total White Count
Platelet
Fasting Glucose
Hemoglobin A1C
Fasting Insulin
Triglycerides
HDL
LDL
Total Cholesterol
SGOT
SGPT
Alkaline Phosphatase
Total Bilirubin
Qualitative CRP
Quantitative CRP
Serum Creatinine
T4
T3RU
TSH
PTH
Serum Iron
Ca
P
Copper
Zinc
Vitamin D
Vitamin B12
Albumin
PT
TIBC
Ferritin