New Patient Information

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sVhV5weC7R9bvxBzAYMdZoXrRGQvDRNW6rG9gKhtbhBrWN98DZ4FjXC9ToLCfYdkHFcUtBqwJjEnXzFUYrJNjm

Please complete the survey below. Upon completion, you will be redirected to our website at dukewls.org. Our staff will contact you within three weeks of receiving your information.

When finished, please be sure to click "submit" at the bottom of the page.

Thank you!

First Name

* must provide value

Last Name

* must provide value

Date of Birth

* must provide value

M-D-Y

Are you a patient in the Duke system?

* must provide value

Yes

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Duke Medical Record Number

Have you previously had either bariatric surgery or a Nissen Fundoplication?

* must provide value

Yes

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Are you seeking another bariatric procedure?

* must provide value

Yes

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Which bariatric procedures have you had previously?

* must provide value

Gastric Bypass (Roux-en-Y)

Lap Band (or other gastric banding)

Sleeve Gastrectomy

Duodenal Switch

Vertical Banded Gastroplasty (VBG)

Nissen fundoplication

Other

Was your surgery here at Duke?

* must provide value

Yes

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Are you currently experiencing a complication of your bariatric surgery?

* must provide value

Yes

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Please call 919-684-4064 to schedule an appointment. Please inform the scheduler that our office is requesting a long-term postop group appointment. At this appointment you will have the opportunity to request a one-on-one evaluation with a provider.

If your surgery was performed recently here at Duke, you may call the nurse triage number that was provided to you.

Gender

* must provide value

female

male

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Address

* must provide value

City

* must provide value

State

* must provide value

Zip

* must provide value

Home Phone

Work Phone

Cell Phone

* must provide value

How did you hear about us?

referred by a physician

from a friend/word of mouth

TV/Radio

internet

Referring physician's first and last name

Referring physician's phone #

Race

African-American

Asian

Caucasian

Hispanic

Native American

Other/Not reported

Requested Procedure

* must provide value

Gastric Bypass (Roux-en-Y)

Sleeve Gastrectomy

Duodenal Switch (biliary pancreatic diversion with duodenal switch)

Lap-Band (adjustable gastric banding)

SIPS

Undecided/Other

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Surgeon Preference

Dr. Portenier

Dr. Sudan

Dr. Yoo

Dr. Seymour

Dr. Guerron

Dr. Jain-Spangler

First available

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Hospital Preference

Duke Regional Hospital (Durham)

Duke Raleigh Hospital

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Primary Insurance Company

* must provide value

BCBS NC/SEHP

Blue Cross Federal/Out of State

Medicare

Medicaid

UHC

Cigna

Aetna

Duke Employee

Other

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Do you have Medicare? If you have Medicare in addition to Medicaid, please indicate in the question above your primary insurance as Medicare.

For patients who are Medicaid only, please be aware that bariatric surgery is not a covered benefit (either in NC or out of state).

After much consideration, the Duke Center for Metabolic and Weight Loss Surgery will not be accepting Medicaid as an approved insurance provider for bariatric surgery at this time. Unfortunately we are unable to process your application due to your insurance provider.

Primary policy holder's full name

* must provide value

Primary policy ID

* must provide value

Phone number for primary insurance company

* must provide value

Secondary Insurance Company

BCBS NC/SEHP

Blue Cross Federal/Out of State

Medicare

Medicaid

UHC

Cigna

Aetna

Duke Employee

Other

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Secondary policy holder's full name

Secondary policy ID

Phone number for secondary insurance company

Primary care physician's first and last name

Primary care physician's phone #

Current Height in Inches (5 ft is 60 inches)

* must provide value

Current Weight (Lbs)

* must provide value

Based on your height of ______ inches and weight of ______ lbs, your BMI is

View equation

Your BMI is below 35.0 and could be a factor in your insurance provider denying coverage for bariatric surgery. Should you wish to proceed we would encourage you to complete this application and click "submit" at the bottom of the page when finished.

Hi ______, your BMI is below the level of 35.0 that insurance companies require for bariatric surgery. Given the height and weight provided, your application will not be considered for weight loss surgery. Please consider www.dukedietandfitness.org for other options.

Medical History: please check all problems you have had in the past or had for a long time)

Blood clots in the legs

Blood clots in the lungs

Stroke/CVA

Cancer

Heart attack (Myocardial infarction)

Other Past Surgeries

Heart surgery

Hernia repair

Gall bladder or appendix surgery

Colon or small bowel surgery

Transplant (any kind)

Other major organ surgery (pancreas, liver, kidneys, etc)

Have you ever smoked or used tobacco products?

* must provide value

Yes

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Have you ever received disability benefits (short-term or long-term) for any reason?

* must provide value

Yes

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Are you currently on disability or applying for disability?

* must provide value

Yes

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Is all or part of your disability status related to a psychological, psychiatric, emotional, or cognitive (i.e. memory) issue?

* must provide value

Yes

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What condition(s), disorder(s), diagnosis, or disease(s) led to your disability?

* must provide value

Expand

Please check all that currently apply.

Chest Pain (Angina)

Irregular/Fast Heart Beat (Arrhythmia)

High Blood Pressure (Hypertension)

Reflux Disease/Symptoms (Heartburn)

Stomach Ulcers requiring meds

Anxiety

Nervousness

Depression

Hallucinations

Suicide Attempts

Homocidal Ideations

Have you ever been in counseling?

Psychological Hospitalizations

Latex Allergy

Diabetes requiring medication

CPAP/BiPAP for sleep apnea

Has it been more than 12 months since your last menstrual cycle?

* must provide value

Yes

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Never

Slight Chance

Moderate Chance

High Chance

Sitting and reading

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Watching TV

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Sitting, inactive in a public place (e.g. a theater or meeting)

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As a passenger in a car for an hour without a break

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Lying down to rest in the afternoon when circumstances permit

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Sitting and talking to someone

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Sitting quietly after a lunch without alcohol

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In a car, while stopped for a few minutes in traffic

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