Page 1 of 8 Bariatric & Metabolic Interdisciplinary Clinic Stanford Hospital and Clinics Bariatric & Metabolic Interdisciplinary (BMI) Clinic 900 Blake Wilbur Drive, W0048, MC 5355, Palo Alto, CA 94304 New Patient Coordinator: (650) 736-5800, option 1 Fax: (650) 723-8378 Patient Questionnaire This questionnaire is required. Please complete and return as soon as possible to allow us to schedule your appointment. Name: _______________________________________ DOB: _______________ Age: ___________.
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How to fill out the CA 15-2711-1 - Stanford online
Filling out the CA 15-2711-1 form is an essential step in your process at the Stanford Hospital and Clinics. This guide will help you complete the form accurately and efficiently to ensure your appointment can be scheduled without delay.
Follow the steps to complete the CA 15-2711-1 form online.
- Press the ‘Get Form’ button to access the CA 15-2711-1 form and open it in your preferred online editor.
- Begin by entering your personal information in the appropriate fields, including your name, date of birth, and age.
- Provide your contact details, such as your address and phone numbers. Ensure to list both your home and cell numbers accurately.
- Indicate your email address for any digital correspondence regarding your appointment.
- Fill in the referring physician's details, including the name, address, and phone number.
- In the section regarding your weight loss surgery consideration, provide the duration of your contemplation and the sources from which you obtained your information.
- Answer the questions about your support system, including family and friends' encouragement.
- List major diet programs you have participated in and detail your weight loss history, including significant life events.
- Complete the current habits section, detailing your dietary and exercise practices; please provide estimates for daily calorie intake.
- Input your medical history by checking or detailing any issues from the lists provided, such as cardiovascular or endocrine disorders.
- Complete the surgical history and medication sections, indicating any previous surgeries and current prescriptions.
- Fill out any allergies you may have, specifying the type of reactions you experience.
- Conclude by reviewing your responses for accuracy, then proceed to save the form, download it, print it, or share it as needed.
Complete your CA 15-2711-1 form online today to expedite your appointment process.
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