Free MORBID_OBESITY_2 (27808 - Draft - Indiana

SURGERY FOR THE TREATMENT OF MORBID OBESITY - Page 1 of 3
FOLLOW-UP REPORTS Indiana State Department of Health State Form 53322 (6-07)

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DIRECTIONS - PLEASE READ BEFORE YOU BEGIN: 3 Fill in circles like this: 1 Print firmly and neatly. Not like this: 2 Only use pens with blue or black ink. Mark mistakes like this:

4 Print capital letters only and numbers completely inside boxes.

A 2 C 3
Yes No

5 Please complete all items on form.

Section 1. Patient Information
Change of patient address and/or phone number

Last Name First Name Number & Street Address City County Sex:
Male Female Unknown

MI

Phone Number

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-

State

ZIP Code

Date of Birth (mm/dd/yyyy) Race (select all that apply):
Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

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Age (years)
White Other/Multiracial Unknown

Ethnicity:
Hispanic or Latino Not Hispanic or Latino Unknown

Section 2. Surgery Follow-up Information

Select the follow-up interval for this report:
30 days 60 days 90 days 1 year 2 years 3 years 4 years 5 years

Initial Surgical Procedure(s) Performed:
CPT Code CPT Code CPT Code CPT Code CPT Code

Follow-up Measurements:
BMI: Comorbidities: Waist Circumference:
Inches

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.
ICD-9-CM code

ICD-9-CM code

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ICD-9-CM code

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ICD-9-CM code

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ICD-9-CM code

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Complications and Side Effects:
Death? Yes No

If Yes, cause of death (ICD-10 code) Complications of initial surgery? If Yes, complication(s): Yes No

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Date of death (mm/dd/yyyy)

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/

ICD-9-CM code

.

Date of complication onset

/ /

/ /

ICD-9-CM code

. .

Date of complication onset

/ /

/ /

ICD-9-CM code

.

Date of complication onset

ICD-9-CM code

Date of complication onset

THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3

SURGERY FOR THE TREATMENT OF MORBID OBESITY - Page 2 of 3
FOLLOW-UP REPORTS Indiana State Department of Health State Form 53322 (6-07) Section 2. Surgery Follow-up Information (Continued) Yes No

Complications (continued): Hospitalization for complication(s)?

If Yes, date of hospitalization (mm/dd/yyyy) Status at time of discharge (selet only one): Against Medical Advice Routine/Self-care Home Health Care Rehabilitation: Inpatient Outpatient Skilled Nursing Facility Surgery for complication(s)? Procedure(s) performed: CPT Code CPT Code Yes Nursing Facility Other Hospital

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Length of stay in days

Name of facility

Other Institution, type: Hospice: Home Inpatient Expired Yes No If Yes, date of surgery (mm/dd/yyyy):

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CPT Code

/

CPT Code No

CPT Code

Other invasive treatment required? If Yes, type and description:

Side effects of initial surgery? If Yes, side effect(s):

Yes

No

ICD-9-CM Code

. .

Date of side effect onset

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/ /

ICD-9-CM Code

. .

Date of side effect onset

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/ /

ICD-9-CM Code

Date of side effect onset Yes No

ICD-9-CM Code

Date of side effect onset

Hospitalization for side effect(s)?

If Yes, date of hospitalization (mm/dd/yyyy) Status at time of discharge (select only one): Against Medical Advice Nursing Facility Routine/Self-care Home Health Care Rehabilitation: Inpatient Outpatient Skilled Nursing Facility Other Hospital

/

/

Length of stay in days

Name of Facility

Other Institution, type: Hospice: Home Inpatient Expired THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3

SURGERY FOR THE TREATMENT OF MORBID OBESITY - Page 3 of 3
FOLLOW-UP REPORTS Indiana State Department of Health State Form 53322 (6-07) Section 2. Surgery Follow-up Information (Continued) No If Yes, date of surgery (mm/dd/yyyy):

Surgery for side effect(s)? Procedure(s) performed: CPT Code

Yes

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/
CPT Code

CPT Code Yes

CPT Code No

CPT Code

Other invasive treatment required? If Yes, type and description

Surgeon's Indiana License Number

Name of Surgeon

Address

City

State

ZIP Code

-

Telephone Number

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-

FAX Number

-

Section 3. Additional Information and Comments Comments:

Last Name of Person Completing Form

First Name of Person Completing Form

Phone Number

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-

Date Form Completed (mm/dd/yyyy)

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/

THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3