SURGERY FOR THE TREATMENT OF MORBID OBESITY - Page 1 of 3
FOLLOW-UP REPORTS Indiana State Department of Health State Form 53322 (6-07)
Reset Form
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
-
-
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
/
/
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
.
.
ICD-9-CM code
ICD-9-CM code
.
ICD-9-CM code
.
ICD-9-CM code
.
ICD-9-CM code
.
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
.
Date of death (mm/dd/yyyy)
/
/
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
/
/
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):
/
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
/ /
/ /
ICD-9-CM Code
. .
Date of side effect onset
/ /
/ /
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
/
/
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
-
-
FAX Number
-
Section 3. Additional Information and Comments Comments:
Last Name of Person Completing Form
First Name of Person Completing Form
Phone Number
-
-
Date Form Completed (mm/dd/yyyy)
/
/
THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3