THOP

ACS Metabolic and Bariatric AccreditationThank you for contacting The Hospitals of Providence Weight Loss Center West.

Please follow the instructions provided in order to process your application.

If you have questions, please call The Hospitals of Providence Weight Loss Center West at 915-577-7930.

  • 1 Patient Information
  • 2 Responsible Party Information
  • 3 Hospital History
  • 4 Sleep Disorders Questionnaire
  • 5 Medical History or Symptoms
  • 6 Medication Log
  • 7 Consent To Contact

Patient Information

Gender:

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Marital Status

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How did you hear about our program?
Mobility needs
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  • 1 Patient Information
  • 2 Responsible Party Information
  • 3 Hospital History
  • 4 Sleep Disorders Questionnaire
  • 5 Medical History or Symptoms
  • 6 Medication Log
  • 7 Consent To Contact

Responsible Party Information

Please enter phone number without dashes (ex. 9017651000)

Please enter phone number without dashes (ex. 9017651000)

Insurance Information - A Copy of your insurance Card(s) - Front and Back - Is Required.

First Insurance

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Second Insurance
If you do not have a second insurance, please do not complete this section.

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In Case of Emergency Notify (Other Than Responsible Party)

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  • 1 Patient Information
  • 2 Responsible Party Information
  • 3 Hospital History
  • 4 Sleep Disorders Questionnaire
  • 5 Medical History or Symptoms
  • 6 Medication Log
  • 7 Consent To Contact

Hospital History

Please list any hospital stays you have had

First Event
Second Event
Third Event
Have you had previous weight loss surgery?
Do you have an abdominal mesh from a previous surgery?
Have you or any of your family members had any type of problem with anesthesia?

Weight History

BMI Calculator

Which procedure do you prefer?
  • 1 Patient Information
  • 2 Responsible Party Information
  • 3 Hospital History
  • 4 Sleep Disorders Questionnaire
  • 5 Medical History or Symptoms
  • 6 Medication Log
  • 7 Consent To Contact

Sleep Disorders Screening Questionnaire

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 daytime?
Has anyone observed you stop breathing during your sleep?
Do you have or are you being treated for high blood pressure?
BMI more than 35k/m2?
Age over 50 years old?
Neck circumference >16 inches (40cm)?
Gender: Male?
Do you have sleep apnea?
Has anyone ever told you that you snore?
Has anyone ever told you that you stop breathing while sleeping?
Do you wake up with a headache?
Have you ever had a sleep study? If yes when/where?
Do you use a BI-PAP or C-PAP machine? If so, what is the name?
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  • 1 Patient Information
  • 2 Responsible Party Information
  • 3 Hospital History
  • 4 Sleep Disorders Questionnaire
  • 5 Medical History or Symptoms
  • 6 Medication Log
  • 7 Consent To Contact

Medical History or Symptoms

Review of Symptoms: Please indicate any personal medical history below:

Genitourniary
Psychological
Neurological
Respiratory
Cardiovascular
Gastrointestinal
Endocrine
Musculoskeletal
Other Conditions
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  • 1 Patient Information
  • 2 Responsible Party Information
  • 3 Hospital History
  • 4 Sleep Disorders Questionnaire
  • 5 Medical History or Symptoms
  • 6 Medication Log
  • 7 Consent To Contact

Medication Log

Medication Log

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  • 1 Patient Information
  • 2 Responsible Party Information
  • 3 Hospital History
  • 4 Sleep Disorders Questionnaire
  • 5 Medical History or Symptoms
  • 6 Medication Log
  • 7 Consent To Contact

Consent To Contact

 Please review our Notice of Privacy Practices and acknowledge receipt below:
Notice of Privacy Practices .