Dr. Emad Guirguis 149 Bayfield St, Barrie, ON, L4M 3B3 Office: (705) 737-3933 Fax: (705) 737-1176 www.lakeviewsurgery.com Bariatric Referral Form Referring Physician Information (Please Print) Referring Physician’s Name Phone # Billing # Referral Date (dd/mm/yyyy) Patient Information (Please Print) Surname Given Name Street Address Home Telephone # Date of Birth (dd/mm/yyyy) City Business Telephone # Postal Code Health Card # Reason for Referral Current Weight: ________________  lb.  kg.  Actual  Estimated Current Height: ________________  cm.  inches  Actual  Estimated Calculated BMI: ________________ Patient’s Weight Loss Goals: ___________________________________________________ Obesity to discuss Bariatric Management, including: Laparoscopic Adjustable Gastric Band, Gastric Bypass and Gastric Sleeve. Does Patient currently have a LAP Band?  Yes  No If yes, is patient interested in the Re-Entry Program for Medical Management and LAP Band Revisions and Adjustments?  Yes  No Past Medical History Medical/Surgical History, Previous Weight Loss Surgery: ______________________________ _____________________________________________________________________________ Previous problems with anesthesia (ie; Malignant Hyperthermia, Difficult Intubation, etc): ____ _____________________________________________________________________________ Medication List: _______________________________________________________________ _____________________________________________________________________________ Allergies: ____________________________________________________________________ _____________________________________________________________________________ Please fax completed forms to (705) 737-1176 Dr. Emad Guirguis 149 Bayfield St, Barrie, ON, L4M 3B3 Office: (705) 737-3933 Fax: (705) 737-1176 www.lakeviewsurgery.com Past Medical History (Questions Regarding Patient’s Health History) 1. Does the patient have any psychiatric illness?  Yes  No 2. Does the patient have a history of substance abuse?  Yes  No  Alcohol  Smoking  Other Drugs  N/A 3. Has the patient had previous liposuction?  Yes  No 4. Does the patient’s current weight cause significant issue when performing their daily activities or employment duties?  Yes  No 5. Is the patient’s current weight preventing joint replacement surgery?  Yes  No 6. Has the patient tried the behavioral programs that conform with the Canadian Clinical Practice Guidelines on management of obesity?  Yes  No 7. Does the patient have Type-2 Diabetes of impaired glucose fasting?  Yes  No Currently controlled by medication?  Yes  No  N/A 8. Does the patient have hypertension?  Yes  No Currently controlled by medication?  Yes  No  N/A 9. Does the patient have dyslipidemia?  Yes  No Currently controlled by medication?  Yes  No  N/A 10. Does the patient have sleep apnea?  Yes  No Currently controlled by medication?  Yes  No  N/A 11. Does the patient use a CPap device?  Yes  No Currently controlled by medication?  Yes  No  N/A 12. Does the patient have gastroesophageal reflux (GERD)?  Yes  No Currently controlled by medication?  Yes  No  N/A 13. Does the patient have end stage renal disease or require dialysis?  Yes  No Currently controlled by medication?  Yes  No  N/A 14. Does the patient have severe cardiac or respiratory disease?  Yes  No Currently controlled by medication?  Yes  No  N/A 15. Does the patient have liver disease?  Yes  No Currently controlled by medication?  Yes  No  N/A 16. Does the patient have history of family history of auto immune disorder?  Yes  No Currently controlled by medication?  Yes  No  N/A _________________________________________________ Referring Physician (Please Print) __________________ Date _________________________________________________ Referring Physician Signature __________________ Date Please fax completed forms to (705) 737-1176