Contact & Scheduling Surgery – Clark Gerhart MD FACS FASMBS

SCHEDULING SURGERY WITH DR. GERHART

Step 1
Fill out and return a Medical History Form below.

Step 2
Gather all your medical test results and reports from any operations you have had in the past.

Step 3
Contact Susan Cerrata at my office at and she will help you send all your records to our office by fax or email at [email protected]

Step 4
Dr. Gerhart will carry out a review of your records and call to discuss your situation.

Step 5
A scheduler from my office will call you to schedule tests or surgery.

MEDICAL HISTORY FORM

DEMOGRAPHICS
Your Name*
First Last
Date of Birth*
Email*
Enter Email Confirm Email
Telephone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Physician Name
First Last
Primary Physician Phone
Cardiologist Name
First Last
Cardiologist Phone
Gastroenterologist Name
First Last
Gastroenterologist Phone
Surgeon Name
First Last
Surgeon Phone
Other Physician Name
First Last
Other Physician Phone
Medical insurance carrier name
Member Name
ID number
Next of kin that we may notify
First Last
HISTORY OF PRESENT ILLNESS
Description of current problem/symptoms:
- -Bariatric patients include weight history and weight loss programs used in past and amount of weight lost with each.
- -Adhesion patients describe pain and any gastrointestinal symptoms, along with any hospitalizations for these symptoms.
- -Hernia patients describe pain and if hernia is causing gastrointestinal symptoms.
- -Gastroparesis patients include extent of nausea and vomiting, along with any hospitalizations for these symptoms.
Enter description of current problem/symptoms here:*
When did the problem begin
Describe nature of symptoms (example: Burning, stabbing, dull, etc.):*
Describe Location of symptoms:*
Describe severity: (10 most severe – 1 mild):
PAST MEDICAL HISTORY
List other medical problems:*
List prior operations: (What operation, date and at what hospital)*
List of medications: (name, dose)*
Medication allergies:*
SOCIAL HISTORY
Alcohol use:
- Never
- Socially
- Multiple times a week
Cigarette use:
- Never
- Currently
- Previously
FAMILY HISTORY
(List illness in these relatives)
Mother
Father
Siblings
Grandparents
REVIEW OF SYSTEMS
(Check any symptoms not mentioned above)
Check all that applies
- Fever
- Chills
- Sweats
- Weight Loss
- Weight Gain
- Chest Pain
- Palpitations
- Shortness of breath
- Pain with breathing
- Nausea
- Vomiting
- Diarrhea
- Blood in urine
- Blood in stool
- Abnormal menstruation
- Pain in legs when walking
- Leg swelling
- Dizziness
- Tremors
- Seizures
- Other (enter in box below)
Enter other symptoms below:
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Email
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Clark Gerhart MD FACS FASMBS

Robotic General and Bariatric Surgeon

Office Contact Information

Hospital Information

Commonwealth Bariatric Center

SCHEDULING SURGERY WITH DR. GERHART

MEDICAL HISTORY FORM