Established in 2009

Jump6 was the first clinic in Canada to offer the intragastric balloon for weight loss and still continues to assist thousands of men and women in achieving their weight loss goals.

Intake Form

Dr. Name


Pre-Procedure History Questionaire

Do you allow us to communicate with your family Physician? YesNo
Is this visit regarding a Worker's Compensation Claim? YesNo
How did you hear about the Jump6?
G.P.FriendYellow PagesMagazineNewspaperInternet

Other

1. Are you taking any medicine or pills for your heart?YesNo

2. Are you taking any medicine or pills for your blood pressure? YesNo

3. Are you taking any medicine or pills (including inhalers) for your breathing? YesNo

4. Do you have: Shortness of breathIrregular heartbeatPalpitationsHeart murmurAngina

5. Do you have: A daily coughAsthmaBronchitisLung disease

6. Do you smoke? YesNo

7. Do you consume alchohol? YesNo

8. Have you had any recent change in weight?YesNo
GainLoss

9. To the best of your knowledge, are you ALLERGIC to anything? YesNo

10. Within the last year have you taken any medicine or pills for rheumatism, arthritis or allergies? YesNo

11. Are you taking a drug called CORTISONE, PREDNISONE OR ACTH, or have you taken it within the last two (2) years? YesNo

12. Have you taken any tranquilizers or NERVE PILLS in the last three (3) weeks? YesNo

13. Have you ever been under the care of a psychiatrist? YesNo

14. Do you take any MEDICINE, PILLS, EYE DROPS, INJECTIONS (also include any non-prescription drugs, inhalers or herbal preparations)? YesNo

15. Do you have diabetes? YesNo

16. Do you have epilepsy? YesNo

17. When was your last General Anaesthetic?

18. Have you ever had a REACTION or COMPLICATION to a LOCAL or GENERAL anaesthetic? YesNo

19. Has anyone in your family ever had a reaction to anaesthetic? YesNo

LocalLocal/SedationGeneral

IT IS VERY IMPORTANT TO REFRAIN FROM TAKING ASPIRIN OR MEDICATION CONTAINING A.S.A. FOR AT LEAST TWO WEEKS PRIOR TO YOUR PROCEDURE.

20. Have you or anyone in your family ever been tested for MALIGNANT HYPERTHEMIA or had a malignant hyperthermia reaction (high body temperature as a reaction to drugs used during surgery)? YesNo

21. Do you suffer from sleep epnea? YesNo

22. Have you ever been tested for H.I.V. antibodies (A.I.D.S.)? YesNo

23. Do you or anyone in your family bleed excessively? YesNo

24. If you have ever had any of the following, if yes, please select them and explain:
HepatitisKidney diseaseRheumatoid arthritisPhlebitisHeart diseaseLiver disease or jaundiceAnemiaCancerEnlarged lymph glandsStrokeBlackoutsHiatus herniaUlcerTransient ischemic attacks (TIA's)

25. List any OPERATIONS you have had in your life:

26. List below the illnesses you have had during your life not already noted on this form:

27. If female, are you pregnant? YesNo

Date of last menstrual period:
Are you breastfeeding? YesNo
Are you on the birth control pill? YesNo

28. Have you ever tested positive for any of the following:

CdiffacileMRSAVRE
Date:

Questions 29 - 34 to be answered when having the jump6 procedure(on the day of procedure)

29. Do you have a cold at present? YesNo

30. Do you have:
Chipped teethFalse teeth, upperFalse teeth, lowerFalse teeth, bracesLoose teethPartial plate or permanent bridge, upperPartial plate or permanent bridge, lowerContact lensesJewelry

31. Who is driving or accompanying you home?

32. Have you signed the Consent for Operation? YesNo

33. When did you last have something to eat or drink?

34. Contact in Emergency:


B.P.:
T.:
P.:
Chest x-ray:
E.K.G.:
Hgb.:
Urinalysis:
Weight:
Height:
Age:
Sex:

Date reviewed with patient:

Signature of nurse:

The findings contained in this questionnaire have been noted:

Anaesthetist

I have reviewed this patients chart:

Anaesthetist

Date:

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