Shelby Baptist Medical Center Bariatric Program Alabaster, AL 35007 Rex A.Sherer M.D.FACS Richard D.Stahl M.D.
FACS Timothy Christopher M.D.FACS Vincent Gardner M.D.FACS ).Patient Signature Witness Relationship to Patient
Shelby Baptist Medical Center Bariatric Program Alabaster, AL 35007 Patient Information Form The staff of Cahaba Valley Surgical Group, P.C.
thank you for entrusting us with your healthcare.
Please read this statement carefully and sign at the bottom of this form.I acknowledge that I am presenting to this office for evaluation and treatment, which may include surgery.
I authorize the release of any medical, insurance or other information necessary to treat me and coordinate my care, to process claims on my behalf, and authoCahaba Valley Surgical Group to do so if I have indicated that I have insurance for my services.
I agree to be fully responsible for all lawful debts incurred for services I receive from Cahaba Valley Surgical Group, P.C., as well as medical services provided in any hospital setting necessary, whether covered by my insurance or not, including any collections fees if I do not pay my bill.
I that my insurance may have a deductible, coinsurance, non-covered services, and/or pre-existing condition provisions and I will be fully responsible for any patient responsibilities as indicated by my insurance company.(or Responsible Party/Guardian) Demographic Information:Todays Date: Last By:
Date of Birth:
Marital Status: M S W D Part.DL #:< # : Spouse: Occupation: Financially Responsible Party: Relationship:
Contact Info: Billing Address: Is your billing address different than the address above?Do you have health insurance you want us to file? Yes Is this visit due to injury or accident? No Yes Is this a workers compensation claim? Insurance Co.#1Group # Effective Date:Are you this policy?List the name or subscriber of this policy EXACTLY as listed on the insurance card:Subscriber DOB: SSN: -
#2Group # Effective Date: Are you this policy?List the name or subscriber of this policy EXACTLY as listed on the insurance card:Subscriber DOB:Who is your referring physician?City/ST Who is your primary physician (if different)?
City/ST Privacy Notice: Please note that we maintain a Notice of Privacy Practices, which is posted at several locations in our waiting room.We he front desk that we encourage you to take.List any individuals with whom you give us permission to discuss your account and medid to treatment, diagnosis, medications, test results or other types of protected health information in order to facilitate or coordinate treatment and payment for your services
You understand that the release of your information is voluntary and does not affect your access to treatment.
You can choose NOT to disclose your information if you wish.
You can revoke this authorization at any time by writing to Cahaba Valley Surgical Group, PC, or by filling out a new form.Name
Relationship Contact #
Relationship Contact #
Relationship Contact #
Shelby Baptist Medical Center Bariatric Program Alabaster, AL 35007 Medical Evaluation Form Todays Date: Patient Name _________________________________ /
Age Patient Height: ____________ Weight lbs.
(Body Mass Index, if known)Primary Care Physician: Specialist ( eg.Cardiologist) Referring Physician) Reason for visit): History (Check or circle all that apply) Surgical HistoryNone (Check or circle all that apply and indicate the year) Medications:
please list all current medications, dose strength, and frequency taken
please include supplements, vitamins, &
herbs Drug Allergies: (please list drug and reaction) Other Allergies: Historyplease list illness in your family and/or cause of death ( if applicable ) Adopted or unknown Please indicate below significant medical problems of family members.
Indicate which family members by checkingappropriate column.Mother Father Brother Sister
Heart Disease High Blood Pressure Diabetes Cancer (Type) Other: Social History:
(check or circle which best describes you)
Single Divorced (grade/level ____________)
Disability (due to ___________________________ ; year Do you now or have you ever?
Yes No ( long: StoppedUsed illicit drugs?
Yes No ( long: StoppedUsed tobacco? long: Stopped Yes No ( long: StoppedShelby Baptist Medical Center Bariatric Program Alabaster, AL 35007 Medical Evaluation Form (Page you currently experiencing.? (Please circle all that apply) Constitutional / General Or None of TheseWeight gain
Weight loss Fever Chills
Body aches Genitourinary (Urologic, GYN)Or None of TheseBlood in urine
Burning on urination
Pelvic pain Difficulty voiding Incontinence/wetting Vaginal discharge Abnormal uterine bleeding Eyes Or None of TheseImpaired vision Blurred vision
Recent changes in vision Neurological Or None of TheseHeadache
Seizure difficulties HENT (Ear, Nose Throat)
Or None of TheseHearing loss
Sinus drainage Neck tenderness
Thyroid mass Musculoskeletal Or None of TheseJoint pain
Muscle weakness Muscle cramps
Muscle Pain Breast Or None of TheseBreast pain
Nipple drainage Breast Tenderness Or None of TheseCold intolerance
Hair loss Hot Flashes Cardiovascular (Heart) Or None of TheseChest in legs/feet
Leg pain with
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