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Step Four: Program Packet and Checklist

Your program packet, which contains the information required prior to your first evaluations, will be given to you at the "Introduction to the DHMC Bariatric Surgery Program" meeting.

All items in this packet must be completed and sent to us. Psychological evaluations may be sent to us directly from the provider. Incomplete packets will be returned.

Note: Patients who receive their primary care at Dartmouth-Hitchcock Medical Center in Lebanon and at Dartmouth-Hitchcock Clinic in Manchester and Nashua do not need to send in their medical records, but do need to send in the checklist, the psychological evaluation, signed agreement, weight chart, and diet journal.

As you are putting your packet together, you should begin viewing and taking the quizzes for the Bariatric Educational Seminars and losing weight (Steps Five and Six).

Send your completed packet to:

Dartmouth-Hitchcock Medical Center
Attention: Bariatric Surgery
One Medical Center Drive
Lebanon, NH 03756

Use the following checklist to ensure your packet is complete

  1. Information from your primary care physician (family doctor), including:
    • A copy of your full medical history, including a review of systems, previous medical and surgical history, problem list, current medication list, and vital signs with weight.
    • A record of a physical exam given to you by your family doctor within the past year. This must include a head to toe assessment. Routine screening tests, such as mammogram, pap smear, and colon cancer screening should be up to date.
    • Fasting blood work, all done within the past year, may be done by your family doctor or at DHMC on the day of your first appointment at DHMC. This lab work must include:
      • CBC
      • Comprehensive metabolic profile
      • Fasting glucose
      • Folate
      • GGT
      • HgA1C and fasting insulin level**
      • Iron, ferritin, iron saturation
      • Lipid profile
      • PTH
      • TSH
      • Uric acid
      • Vitamin A
      • Vitamin B12
      • Vitamin D (25 hydroxy only)

    ** Diabetic patients should have a urine test for microalbumin and do not need a fasting insulin level done. VT Medicaid patients need a H pylori test.

    • A documented history of previous weight loss attempts over the last five years.
    • If you have asthma or lung problems, a record of a pulmonary function test (spirometry), done within the past two years.
    • Documentation of any of the following tests (ONLY if they have been done previously):
      • Sleep study/ CPAP titration study
      • Stress test and/or cardiac catheterization
      • Upper endoscopy (EGD) or colonoscopy
      • Cardiac echocardiogram (if done in the past four years)
    • A record of a psychological evaluation (minimum of two visits) performed by a mental health professional. This record is most often completed and sent to us by the mental health provider. Please choose a provider who is familiar with Bariatric surgery and is covered by your insurer.
    • Documentation about your current medical insurance company

    Before sending in your packet, make a copy of the requested information for your records.

    Note: It is highly recommended that you have an evaluation by a Sleep Disorders Center as soon as possible if you have symptoms or findings suggestive of sleep apnea, which is very common in patients with obesity.

    If you have a neck circumference greater than 16 inches, feel tired during the day and while driving, fall asleep easily, snore loudly, wake up frequently during the night, have a sore throat in the morning, morning headaches, please have an evaluation. Your process to surgery will be delayed if the testing is not done prior to surgery. Treatment for sleep apnea may save your life!

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