Office Hours:  Mon - Thur 8:00 AM - 7:00 PM | Friday 8:00 AM - 3:00 PM

9100 Andermatt Drive, Suite 1, Lincoln, NE 68526

info@heartlandsurg.com

Call: (402) 227-8157 or (402) GET-HELP

Call: (402) 227-8157 or (402) GET-HELP

Patient Medical History

Home>Patient Medical History
Fields marked with an * are required
Date this form was completed: *
We need to know about your most recent exams for routine health. Please tell us the dates and details requested below:
Do you have any disabilities? *

Do you have any ALLERGIES? *
Do you have any sensitivities to latex or anesthesia? *
Do you have any sensitivities to any medications? *
Have you ever been diagnosed or suffered from any weight related diseases? If so, please select all that apply from the list below:
Have you ever been diagnosed with diabetes?

Only patients who have been diagnosed with type I or type II diabetes need to answer the following questions in this diabetic section. If you are not diabetic, you can skip this section and go directly to the next section.
If you are diabetic or have been diagnosed with type I or type II diabetes, what was the date of diagnosis?
Date of Last Foot Exam?
Date of Last Eye Exam?
Date of Last Dental Exam?
Date of Last diabetic exam?
Date of Last A1C?
Are you currently using a continuous glucose monitoring device (CGM)?
If you are using a continuous glucose monitoring device (CGM), what brand do you use?
Are you currently using an insulin pump?
If you are using an insulin pump, what brand do you use?

Only patients who have been diagnosed with an endocrine disorder or who are using testosterone need to answer the following questions in this endocrine section.
Are you currently using testosterone?
Date of last testosterone injection?
Have you ever been diagnosed with any of the following thyroid disorders?
Date of thyroid diagnosis?
Are you currently breast feeding?
Are you currently pregnant?
Are you planning to get pregnant in the near future?
Current Employment Status: *
What is the highest grade or level of education you have completed? *
Have you ever served in the military? *
We need to know about your past surgical history and hospitalizations. Please tell us the dates and details requested below:
Date of Last Physical:
Physical Results:
Date of last EGD? This is an examination of your upper GI tract using a camera held on to a flexible tube called an endoscope:
EGD Results:
Date of Last Surgery:
How are you sleeping currently? Please select one or more options below which best describe your sleep life:
Do you currently utilize a CPAP machine when you sleep?
Have you ever participated in a sleep study?
If you have participated in a sleep study, what were the results?
Below is a series of questions known as the STOP BANG questionnaire. Please answer the questions accordingly.
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
Do you often feel TIRED, fatigued, or sleepy during the daytime?
Has anyone OBSERVED you stop breathing during your sleep?
Do you have or are you being treated for high blood PRESSURE?
Is your BMI more than 35kg/m2?
Is your AGE over 50 years old?
Is your NECK circumference >16 inches (40cm)?
Is your GENDER male?
Below is a series of questions known as the Binge Eating Disorder Screening (BEDS-7). Please answer the questions accordingly. Please note - if you answer "NO" to question #1, the remaining questions 2-7 do not apply to you.
1. During the past 3 months, did you have any episodes of excessive overeating (i.e. eating significantly more than what most people would eat in a similar period of time)? *
2. Do you feel distressed about your episodes of excessive overeating? *
3. During your episodes of excessive overeating, how often did you feel like you had no control over your eating (i.e. not being able to stop eating, feeling compelled to eat, or going back and forth for more food)? *
4. During your episodes of excessive overeating, how often did you continue eating even though you were not hungry? *
5. During your episodes of excessive overeating, how often were you embarrassed by how much you ate? *
6. During your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterward? *
7. During the last 3 months, how often did you make yourself vomit as a means to control your weight or shape? *
Below is a series of questions known as the Night Eating Questionnaire. Please answer the questions accordingly.
On most days, do you experience loss of appetite in the morning?
How often do you typically eat breakfast (after your final morning awakening)?
How much food do you generally eat after 7pm as a percentage (%) from 0-100?
Do you have trouble falling asleep at night?
Please share with us if you have received the following vaccinations:
Have you received an influenza vaccination?
Have you received a pneumonia vaccination?
Have you received the COVID-19 vaccination?
If you have received the COVID vaccine, which brand did you get?
Date of 1st COVID dose:
Date of 2nd COVID dose:
Date of 3rd COVID dose:
Date of 4th COVID dose:

Please provide a brief family history using the selections below:
History of Obesity: *
History of Depression: *
History of Cardiovascular Disease: *
History of Cardiac Problems: *
History of Hypertension or High Blood Pressure: *
History of Diabetes: *
History of Suicide: *
History of Mental Illness: *
History of Substance Use / Abuse: *
History of Cancer: *
History of Stroke or Heart Attack: *
History of Dementia, Alzheimer's or any Memory Problems: *

Whether you are here for medical care or weight loss, you are in the right place. Please answer the following questions to help us get to know you better so that we can provide you the best care possible. We want to know the real YOU so we can help.
Have you ever used any form of nicotine product(s)? If yes, please indicate which types you have used below or select none: *
Do you currently use any alcohol? *
Do you currently use any drugs? We need to know about recreational use, illicit use or any use of drugs not prescribed: *
After 30 years of providing surgical care, Dr. Fermelia no longer operates. He exclusively provides office based obesity medicine as of 2024.
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