Bariatric Surgery. Website: http//baybariatricsurgery.com
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1 Bay Bariatric Surgery Kevin L. Huguet, M.D. General Surgery Laparoscopic Surgery Bariatric Surgery George Rossidis, M.D. General Surgery Minimally Invasive Surgery Bariatric Surgery Website: http//baybariatricsurgery.com Nutrition Questionnaire Please bring the form with you on your initial clinic visit. Date Name 1. How long have you been considering weight loss surgery? Weight History 2. What is your current weight? LBS 3. What is your desired goal weight at months after surgery? LBS 4. How many pounds do you need to lose to achieve your weight goal? LBS 5. When did your weight problem begin? childhood adolescent Teenager 10 years ago 20 years ago 30 years ago Throughout life other 6. What do you think is reason for your weight gain? Injury pregnancy overeating poor eating habits heredity Lack of exercise marriage smoking cessation stress Divorce other 7. What has been your highest adult weight? LBS 8. When you lost weight in the past, how many pounds did you lose on average with each attempt? Weight loss small (<15 lbs) moderate (15-49 lbs) large (>50lbs) 9. What has been you most successful diet? Why Exercise History 10. Do you currently exercise? yes no If yes, what do you do for exercise, Exercise Days/week Time spent If No, Why Diet Assessment 11. How many meals per day do you eat? one meal two meals three meals one to two meals two to three meals three or more meals
2 If you skip meals what meal(s) do you usually skip: Breakfast lunch dinner How many days a week do you skip this meal 12. I eat out for Breakfast rarely sometimes often daily Lunch rarely sometimes often daily Dinner rarely sometimes often daily 13. Are your meals? Large portion extra large portions high fat high carbohydrate High sugar 14. How often do you snack? A.m. snack p.m. snack evening snack snack between all meals Grazing on food throughout the day 15. What beverages do you drink (please mark how many ounces you drink of each daily) water whole milk diet soda 2% milk regular soda 1% milk regular coffee skim milk decaf coffee juice regular tea sweet tea decaf tea unsweetened tea 16. Do you drink alcohol? yes no If yes what type how much and how often. 17. Do you take a Multivitamin? yes no 18. Do you smoke? yes no if quit, when From the list below what triggers you to eat: Availability of food Loneliness Habit Lack of appetite awareness External cues Stress Social situations Sadness other Anger Depression Boredom Hunger Self reward Comfort PMS Anxiety How would you describe your eating habits? Skip one meal per day feeling disgusted or guilty after Reported often eating (i.e. grazing) overeating Rapid eating Eating large amounts of food Eating until uncomfortably full throughout the day Eating alone out or embarrassment Middle of the night eating
3 Today s Date: Personal Data Full Name: Birth Date: Soc Security #: Address: City, State, ZIP: Work Phone: Home Phone: Address: Occupation: Marital Status: Insurance Company: Policy Holder s Name: SS# of Policy Holder: Policy Number: Insurance Information Address: City, State, ZIP: Person Contacted: Telephone: Fax Number:
4 Family Physician: Address: City, State, ZIP: Office Phone Family Physician Information FAX number: Section II Body Size and Weight Information- List Maximum for Each Year Weight 1992: Weight 1997: Weight 1993: Weight 1998: Weight 1994: Weight 1999: Weight 1995: Weight 2000: Weight 1996: Weight 2001: Current Weight: Height: Waist Measurement: Previous Attempts at Weight Loss Program: Year: Months: Physician Supervised? Lbs. Lost: Weight Regained?
5 List any other Attempts: List Medications Used to Lose Weight and Results: Describe any Family History of Obesity: Section III Do you have a Psychiatrist: If Yes: Psychiatrists Name: Address: City, State, ZIP: Office Phone: Date Last Seen: Yes No
6 Please List all Allergies: Please List all Medications Currently Taking and Dosages: List Prior operations (indicate if done with laparoscope): Describe in your words how your obesity is affecting your life:
7 Section IV Obesity and Selected Organ Function Check all that apply Cardiovascular Heart problems (requiring medication) Chest Pains Racing Heart/skipping High blood pressure (requiring medication) Chest tightness Shortness of breath (SOB) High Cholesterol (requiring medication) High Triglycerides (requiring medication) Feel tired all the time Diabetes Diabetes Type I or II (requiring medication) Pre-Diabetic (abnormal glucose tolerance test) Gestational Diabetes Age of Diagnosis Hypoglycemia (low blood sugar) Thyroid Problems Thyroid Problems (requiring medication) Gastrointestinal Gallbladder Problems Removed? Stomach Ulcers (requiring medication) Heartburn Daily? Nocturnal? Regurgitation? Requiring Medication? Diarrhea or constipation Respiratory Asthma Last attack?? Bronchitis # of times in past 2 years Is it recurring? Yes No Pneumonia Blood clots in lungs Smoker Starting age When did you stop? Smokeless Tobacco Sleep Apnea Snore Wake up gasping with a smothered feeling? Using CPAP or BI-PAP
8 Check all that apply Musculoskeletal Mild Moderate Severe Hip Pain Knee Pain Ankle Pain Feet Pain Back Pain Neck Pain Arthritis Check all that apply Degenerative Joint Disease Using antiinflammatory or pain medicine Swelling in the legs Swelling in the feet Swelling in the hands Varicose veins Ulcers of the legs Problems with Pain Inflamed Red leg veins For Females Problems Conceiving Are you regular? Any pain with period? Loss of urine
9 Nero- Psychiatric Depression because of obesity? requiring medication? Seizures requiring medication? Severe Headaches requiring medication? Visual Problems Been in counseling History of alcohol abuse. How long have you been dry History of drug abuse. How long have you been clean Eating disorder. Bulimia Anorexia-Nervosa Family History (parents, grandparents, brothers, sisters) Obesity Diabetes Heart Disease High Blood Pressure Cancer & Type Arthritis Early Death & Cause Parents Grandparents Brothers Sisters Other
10 Sleep Apnea Self Test (You do not need to complete if you know you have sleep apnea) Do you Snore? Have you been told that you hold your breath or stop breathing during sleep? Do you wake up Gasping for Breath? Do you awaken with headaches Do you fall asleep frequently while reading? Have you fallen asleep while driving or stopped at a light? Do you have jerking movements while sleeping? Do you still feel exhausted after 8 hours of sleep? Total # of YES answers: YES NO If you answered YES to more than four of the above questions, you may have sleep apnea and you should talk to your doctor about a sleep study.
11 Impact of weight on Physical Functions Please check the answer in the right column according to how well it describes you in the past week: Physical Function picking up objects tying my shoes using stairs putting on or taking off my clothes with morbidity crossing my legs I feel short of breath only with mild exertion I am troubled by painful or stiff joints My ankles and lower legs are swollen at the end of the day I am worried about my health Self Esteem Because of my weight I am self conscious Because of my weight my self esteem is not what it could be Because of my weight I feel unsure of myself Because of my weight I don t like myself Because of my weight I am afraid of being rejected Because of my weight I avoid looking in mirrors or seeing myself in photos. Sexual Life Because of my weight I do not enjoy sexual activity Because of my weight I have little or no sexual desire Because of my weight I have difficulty with sexual performance Always true Usually true Sometimes true Rarely True Never true
12 Because of my weight I avoid sexual encounters whenever possible Public Distress Because of my weight I experience ridicule, teasing, or unwanted attention Because of my weight I worry about fitting into seats in public places Because of my weight I worry about fitting through aisles or turnstiles Because of my weight I worry about finding chairs that are strong enough to hold my weight Because of my weight I experience discrimination by others Work: (if you are a homemaker or retired, answer this questions with respect to your daily activities) getting things accomplished or meeting my responsibilities Because of my weight I am less productive than I should be Because of my weight I don t receive appropriate raises, promotions, or recognition at work Because of my weight I am afraid to go to job interviews
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Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all
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*521634* Sleep History Questionnaire. Name of primary care doctor:
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EMORY SLEEP CENTER Sleep and Health Questionnaire
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PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
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Legacy Weight and Diabetes Institute 1040 NW 22 nd Ave. Suite 520, Portland, OR Phone: Fax:
Legacy Weight and Diabetes Institute 1040 NW 22 nd Ave. Suite 520, Portland, OR 97210 Phone: 503-413-7557 Fax: 503-413-6547 ** Please use a black of blue pen ** BARIATRIC SURGICAL PATIENT APPLICATION Family
Nutrition Questionnaire
Nutrition Questionnaire Please complete this form to the best of your ability and bring with you to your first nutrition counseling session. Name: Date: KSU #: Last First Background Information Email address