Coastal Center for Obesity, Lap Band, Gastric Bypass, Bariatric Surgery, Weight Loss in Los Angeles and Orange County
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Online Pre-Op Form

Thank you for your interest in Coastal Center for Obesity. Our centers are located in Southern California and Nevada. We treat patients from all over the country, however if you live outside of our area, due to the need for follow-up care, you may be best served by a surgeon within closer proximity. To locate a surgeon closer to you, please contact The American Society of Bariatric Surgeons at www.asbs.org.

The information you provide will help us to determine if you are an appropriate candidate for surgery and assist us in determining if gastric bypass surgery is a covered benefit under your insurance plan. The questionnaire should be completed after you have attended one of our free introductory seminars or viewed our online seminar in its entirety.

All information included on the Pre-Operation Form will be deemed "Protected Health Information" and may be released to insurance payors, health care providers or other "Business Associates" of Coastal Center of Obesity in accordance with Title 45, Code of Federal Regulations, Section 160.103..

Insurance Card

In addition to submitting this questionnaire, please send us a copy of the front and back of your insurance card. You may mail or fax this copy to us.

FAX TO: 310-833-1146

OR

MAIL TO:
Coastal Center for Obesity
Attn: Insurance Dept.
1094 W. 7th Street
San Pedro, CA 90731
Tel. 888-527-5222

Pre Op Questionnaire

Please fill out all the questions as completely as possible. Plan to spend 20 to 40 minutes completing this questionnaire. When finished click the "Submit" button at the bottom of the page to process your information. Items in Red are required to be filled in.

Name
Email Address
Phone
(with Area Code)		 ex. xxx-xxx-xxxx
Address
(max 200 chars)
Billing Address
if different than your home address
(max 200 chars)
Sex Female Male
Age
Height
Current Weight
Birth Date Social Security #:
Driver's License  
Race
Caucasian Black Asian Hispanic Other
Marital Status
Single Married Separated Divorced Widowed
How many children do you have?         Ages
Lifetime maximum weight
Age at which you first became 75 lbs. or more overweight
How do you now perceive your body weight? Less than normal Normal Overweight (75 lbs or less) Very overweight (more than 75 lbs)
How do you believe that others perceive your body weight? Less than normal Normal Overweight (75 lbs or less) Very overweight (more than 75 lbs)
Number of weight loss methods tried pre-op (please provide a number even if you are unsure of the total)
How many times have you lost 20 or more pounds? (answer with a number even if it is only a guess)
Main reason for wanting treatment for weight loss?
INSURANCE
Required:
Please give us all pertinent information regarding your insurance coverage. If you have coverage by more than one carrier, supply information of all.
No coverage Champus Metro
Aetna Medicaid Worker's Comp
Blue Shield Medicare Other
Required:
In order to submit a claim for payment to us for services covered under you policy, we must have your authorization to release medical information to your insurance carrier.		 HMO      PPO      EPO      POS      CASH
Medicare and Medicaid: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. I request that payment under the medical insurance program be made either to me or to Milton L. Owens, M.D., Inc. on any bills for services furnished me by Milton L. Owens, M.D., Inc. during the next 12 month period.

All Other Insurance: I hereby authorize Milton L. Owens, M.D. , Inc. to submit a claim to my insurance carrier or its intermediaries for all covered services rendered by the physician(s) and authorize and direct my insurance carrier or its intermediaries regarding services rendered.

Payment Default: In the event of payment default, I agree to be responsible for any and all collection fees.

I have read and agree to the above statement.
Company Name PRIMARY SECONDARY
Company Address
(max 200 chars)
Company Phone ex. xxx-xxx-xxxx
Insured's Name
Insured's Policy Number
Insured's Group Number
EMPLOYMENT
Are you employed? Yes No
Employer name
Employer phone
Employer Address
Occupation
FAMILY PHYSICIAN
Physician Name
Physician Address
(max 200 chars)
Physician Phone ex. xxx-xxx-xxxx
FAMILY HISTORY
Counting yourself, your full brothers and sisters, and your parents, how many people are in your immediate family?
How many people in your immediate family (yourself included) were at one time or another 75 lbs. or more overweight?
Has any blood relative ever had a problem with Anesthetics (e.g. malignant hyperthermia) Yes No
DOES ANYONE IN YOUR FAMILY HAVE...
...Diabetes? Yes No  Relation:
...High blood pressure? Yes No  Relation:
...Heart disease? Yes No  Relation:
...Gallstones? Yes No  Relation:
OPERATIONS
List all previous
operations/ anesthetics		 OPERATION DATE TYPE OF ANESTHESIA PROBLEMS (if any)
ILLNESSES
List all serious illnesses
MEDICATIONS
What medications are you taking? [Do not forget such things as aspirin, cortisone, blood pressure medication, thyroid, tranquilizers, hormones, birth control pills, laxatives, vitamins, etc.] MEDICINE DOSE AVERAGE FREQUENCY
Have you ever taken Phen-fen? Yes No   If yes, then for how long?
ALLERGIES
Are you allergic to any medications? (If yes, list medications) Yes No
MEDICATION REACTION
Do you have food allergies? Yes No
Check if you have any of these Egg/Soy bean allergy Hives Hay fever Childhood Eczema
EATING HABITS
Do you eat breakfast? 3 or more days a week 1 or 2 days a week
Do you snack at night? 3 or more days a week 1 or 2 days a week
Do you snack during the day? 3 or more days a week 1 or 2 days a week
Do you drink soda or other very sugary liquids? 3 or more days a week 1 or 2 days a week
Do you eat desserts? 3 or more days a week 1 or 2 days a week
Do you eat fried foods? 3 or more days a week 1 or 2 days a week
Do you binge eat? (Bingeing means that you eat a lot more than you feel you should eat.) 3 or more days a week 1 or 2 days a week
How large are your meals compared to normal weight people eating the same meal? Smaller The same Larger
SMOKING AND DRINKING
How many cigarettes (or packs) do you smoke a day?   cigarettes     packs
Do you drink alcohol? Never Rarely (2 times per month or less) Occasionally (once a week or so) Daily
Have you ever been in an alcohol rehabilitation program? Yes No
SLEEPING
How often do you have restless sleep or frequent awakening? 2 or more days a week Fewer than 2 days a week
How often do you have night sweats? 2 or more days a week Fewer than 2 days a week
How often do you snore? 2 or more days a week Fewer than 2 days a week
How often do you have daytime sleepiness? 2 or more days a week Fewer than 2 days a week
How often do you have morning headaches? 2 or more days a week Fewer than 2 days a week
In the past year, has anyone told you that you held your breath for a long time while asleep? Yes No
Do you wake at night with a snort or gasp? Yes No
RESPIRATORY
Spitting of blood? Never Past Now
Have you had bronchitis? Yes No
Have you had emphysema? Yes No
Have you been diagnosed or treated for asthma? Yes No
 If yes, list medications used:
Year of last chest x-ray? Was it normal? Yes No
CARDIOVASCULAR
Chest pain or angina pectoris? Never Past Now
Heart murmur? Never Past Now
Have you ever had palpitations/ arrhythmia Yes No
Have you had a heart attack? Yes No
Have you been diagnosed or treated for High Blood Pressure? Yes No
 If yes, list medications used:
Have you had varicose veins? Never Past Now
Have you had blood clots or phlebitis (inflammation in the leg veins)? Yes No
Year of last EKG? Was it normal? Yes No
Do you have shortness of breath after climbing one flight of stairs? Never Past Now
How many blocks can you walk without having to stop for breath?
How many days a week do you exercise on average?
GASTROINTESTINAL
Tarry black stool or blood in bowel movements? Never Past Now
Crampy abdominal pain? Never Past Now
Chronic constipation? Never Past Now
Frequent diarrhea? Never Past Now
Change in bowel habits? Never Past Now
Hemorrhoids or piles? Never Past Now
Have you been diagnosed as having stomach or intestinal ulcers or other disorders of the gastrointestinal system? Never Past Now
Have you had hepatitis or liver problems? Never Past Now
Ever vomit blood? Never Past Now
Do you have heartburn? Never Past Now
URINARY
Have you had kidney problems? Never Past Now
Burning or painful urination? Never Past Now
Frequent urination? Never Past Now
Feeling you must go immediately? Never Past Now
Do you lose small amounts or urine with coughing or straining? Never Past Now
Blood in urine? Never Past Now
Kidney stones? Never Past Now
GYNECOLOGICAL
Have you had gynecological (female) problems? Never Past Now
Are you or might you be pregnant? Never Past Now
Do you experience menstrual difficulties? None Irregular periods Heavy periods Painful periods
MUSCULOSKELETAL
Arthritis, swollen or painful joints? Never Past Now
Pain in calves or buttocks when walking, relieved by rest? Never Past Now
How often do you have swelling of ankles? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - back? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - hip? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - knee? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - ankle? 2 or more days a week Fewer than 2 days a week
How often do you have joint pain - foot? 2 or more days a week Fewer than 2 days a week
SKIN
Frequent infections? Never Past Now  
Unusual moles or lumps? Never Past Now  
Describe unusual moles or lumps:
HEAD
Eye disease or injury? Never Past Now
Double Vision? Never Past Now
Headaches? Never Past Now
Rarely Occasionally Frequently
Minor Moderate Severe
Epilepsy or seizures? Never Past Now
Brain disease or Strokes? Never Past Now
MENTAL HEALTH
Are you satisfied with your social life? Yes No
Were you ever severely abused?(check all that apply) Emotionally Physically Sexually
Are you satisfied with your sex life? Yes No
How would you rate your self esteem level? Low Medium High
How would you rate your energy level? Low Medium High
Do you have trouble sleeping? Never Past Now
Are you usually tired? Never Past Now
Are you often depressed? Never Past Now
Are you often anxious or nervous? Never Past Now
Do you ever wish you were dead and away from it all? Never Past Now
Have you ever seen a psychiatrist? Yes No
Name
Address
Phone
Have you ever been hospitalized for psychiatric reasons? Yes No
HEMATOLOGICAL
Anemia? Never Past Now
Excessive bleeding or abnormal bruising? Never Past Now
Have you ever received a blood transfusion? Never Past Now If yes, in what year?
ENDOCRINE
Hormone therapy? Never Past Now
Thyroid problem? Never Past Now
Have you been diagnosed or treated for Diabetes? Yes No
 If yes, list medications used:
Have you been told that you have Gallstones? Yes No
METHODS OF WEIGHT CONTROL USED IN THE PAST
Doctor Supervised Programs TYPE WHEN PROGRAM
Rader Institute
Lindora
Fasting
B-6
Amphetamines
Opti-Fast
Schick Center
Medifast
HCG Shots
B-12
Other weight loss pills
Other
Traditional Weight Loss Programs TYPE WHEN PROGRAM
Jenny Craig
Over Eater’s Anonymous
Weight Watchers
Nutri System
"Fat Farms"
Exercise program
Other
Non-traditional Weight Loss Programs TYPE WHEN PROGRAM
Gastric Bubble
Acupuncture
Jaw wiring
Hypnosis
Other
Self Diets TYPE WHEN PROGRAM
Slim Fast
Dieter’s tea
Accutrim
Dexatrim
Cal Ban 3000
Fasting
Other
Popular Diet Programs TYPE WHEN PROGRAM
Scarsdale Diet
Herbal Life
Bahamian Diet
Beverly Hills Diet
Pritikin Diet
Cambridge Diet
R. Simmons’ Deal-A-Meal
Other
Nutritional Programs TYPE WHEN PROGRAM
In-Hospital
Hospital/Clinic Name:
Out-Patient
Hospital/Clinic Name:
Previous Weight Loss Surgery Procedures TYPE WHEN HOSPITAL/CLINIC NAME
J.I. Bypass
Vertical Band Gastroplasty
Vertical Ring
Roux en Y Gastric Bypass
CHOICE OF SURGERY
Which surgery are you interested in: Adjustable LAP-BAND® Surgery
Gastric Bypass
CHOICE OF SURGEON
Do you have a Surgeon Preference? Dr. Owens, Medical Director
PATIENT INFORMATION SEMINAR
Have you attended a patient information seminar? Yes I have attended a live seminar
Yes I have viewed the online seminar in it's entirety
WHO CAN WE THANK FOR THIS REFERRAL?
I heard about
Coastal Obesity from		    Name of newspaper
Name & Address
(if you selected "Physician" or "Coastal Patient") 		Name:

Address:
Final Comments
(max 1000 characters)

If you have filled out all of the answers to the best of your knowledge click the Submit button below.

Don't forget to fax or mail us a copy of the front and back of your insurance card.
Fax: 310-833-1146

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