Post Op Eval

Walking yes no	Dressyes no	Stairsyes no
Work yes no	Playyes no	Tie shoesyes no
Housework yes no	Standyes no	Get upyes no
Childcare yes no	Sityes no	Sexualityyes no
Pick up thingsyes no	Shopyes no	Exerciseyes no
Batheyes no	Clean Selfyes no	Travel yes no

Describe how obesity affects your daily activities.

Medical History:

Do You Have Diabetes or a high sugar?

Describe your diabetes and its treatment.

Do you have shortness of breath?

Describe your shortness of breath.

Do you have sleep apnea or other sleeping difficulties?

(Please complete the Sleep Apnea Form)

Describe your sleep apnea and its treatment.

Do you have lung disease?

Chronic Obstructive Pulmonary Disease, Emphysema or other types of lung disease

Describe your lung disease and its treatment.

Do you have Asthma?

Asthma

Describe your Asthma and its treatment.

Do you have thyroid disease?

Describe your thyroid disease.

Do you have high blood pressure?

Describe your high blood pressure and medicines.

Do have heart disease?

Yes:

Angina
Heart Attack
Heart Failure

Shortness of breath lying down
Sudden shortness of breath at night
Ankle swelling

Describe your heart disease and its treatment.

Do you have a high cholesterol or triglyceride?

Cholesterol Level

Triglyceride Level

Describe your high cholesterol or triglyceride level and the treatment.

Do you have times when you cannot hold your urine (incontinence)?

Describe your incontinence.

Do you have gallbladder disease?

Describe your gallbladder disease.

Do you have arthritis, joint or back pains?

Describe your arthritis and the treatment.

Do you have digestive disease such as reflux or hiatal hernia?

Yes:	Peptic Ulcer, Gastroesophageal Reflux, Hiatal Hernia, Vomiting Blood, Bloody Bowel Movements, Trouble Swallowing, Nausea or Vomiting, Jaundice, Hepatitis or Liver Disease, Diarrhea/Constipation, Hemorrhoids, Abd Pain, Pancreas Disease

Describe your digestive disease and its treatment.

Do you have gynecologic disease?

Describe your gynecologic disease (female problems).

Do you have kidney or bladder disease?

Describe your kidney or bladder disease and its treatment.

Describe your hospitalizations or surgery?

Describe your previous Operations and tell us if you had problems with the surgery

Surgery	Year	Brief Description/Problems
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Have you had Prior Obesity Surgery?

Previous Obesity Surgery: Surgery Type: Year:

Please list your medications and the dose.

Are you Allergic to Penicillin(s)?

(Penicillins include: Amoxicillin, Ampicillin and other antibiotics)

Describe your Penicillin allergy:

Please list your allergies and tell us what happens.

Do you drink alcohol? How much?

Are you a smoker? How much?

Do you have a family history of obesity?

Describe the obesity history in you family.

Are there serious medical illnesses in your family?

Yes?	Diabetes Heart Disease Stroke High Blood Pressure Cancer

Describe the Medical illnesses in your family.

Your Referring Doctor:

Doctor's name?

Street address.

Doctor's City?

Doctor's State.

Zipcode.

Telephone #.

Doctor's Fax #

Very Important

Family Information:

Marital status.

Spouse's name?

Other Comments:

Notes (Any other comments)

Remember: Your Insurance Company's Fax # and your Doctor's Fax # are VERY VERY Important!

This notice describes how information about you may be used and disclosed and how you can gain access to this information. Please review carefully

Contact Information: -Telephones: *** CLOS West: 702-456-4643; Trish Lanman 702-376-3446, Sandy Brubaker 702-376-3647; Jennifer Brubaker 702-376-9339, Dr. Rutledge 702-215-9550 *** CLOS Florida: Flo Ballengee 863-899-3463 Dr. Cesare Peraglie 407-922-3424

Email Us Anytime for Help: Email: Dr. Rutledge DrR@clos.net, *** CLOS West: Trish Lanman Trish@clos.net, Sandy Brubaker SandyB@clos.net Dr. Rutledge DrR@clos.net *** CLOS Florida: Flo Ballengee flo@clos.net, Dr. Peraglie drp@clos.net

Addresses: Address: *** CLOS West Office: Dr Robert Rutledge / CELOS, 98 E Lake Mead Parkway Suite 302, Henderson NV 89015, Office 702-456-4643, Office fax: 702-456-1173, Contacts: Trish Lanman 702-376-3446 Trish@clos.net, Sandy Brubaker 702-376-3647 SandyB@clos.net, Jennifer Brubaker 702-376-9339 Jen@clos.net, Dr. Rutledge 702-215-9550 Drr@clos.net *** CLOS Florida: 40124 Highway 27, Suite 203, Davenport, FL 33837, Flo Ballengee 863-899-3463, Flo@clos.net, Dr. Peraglie 407-922-3424 drp@clos.net

Warning: Gastric Bypass Surgery is a MAJOR surgical procedure. It can be associated with significant risks and complications, up to and including death. Weight loss surgery is a rapidly developing area of medicine. Bariatric surgery is filled with controversy. It is very important to take a careful and deliberate approach to considering surgery for the treatment of obesity.

Disclaimer Notice:-Information on this web site is provided for informational purposes only.
-It is imperative that you consult your own physician regarding the applicability of any opinions or recommendations with respect to your symptoms or medical condition.
-Contact with this web site or Dr. Rutledge over the web site does not constitute a doctor patient relationship and for good quality medical care you must obtain advice and consultation form your own local physician.
-This site is intended as a resource for references on the treatment of obesity for health care professionals and educated consumers.
-The authors and editors have used sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.
-Medical knowledge changes rapidly. In view of the possibility of human error or changes in medical science, neither the authors nor the editors nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information.
This information is not medical advice or diagnosis, nor is it to be construed as medical advice, medical information, medical diagnosis, or medical prescription for curing, removing, or preventing any disease, or related symptoms. You must seek the direct assistance, advice and evaluation of your own personal physician before acting on any information found herein. These statements have not been evaluated by the Food and Drug Administration.
-Readers are Strongly encouraged to discuss and confirm the information contained herein with your own physician.
Copyright Š 1998 The Center for Laparoscopic Obesity Surgery