Bariatric Surgery Follow-up Appointment

First Name *

Last Name *

What surgery did you have? *

Other Procedure

Date of Surgery *

Other follow-up timeframe

What is your current weight in KG? *

Do you have any issues with eating any types of food or drinking fluids? *

How much protein are you having per day? *

How much fluid do you drink per day? *

What other supplements do you take if not listed here? *

How reliable are you at taking your vitamins? *

Please provide details on the symptom(s) of concern *

Do you currently smoke, vape or use any nicotine or cannabis products? *

YesNo

Do you drink any alcohol regularly? *

YesNo

Please provide information about smoking, vaping, cannabis, alcohol or any other drug use below

How many hours do you sleep each day/night? *

How are you looking after your physical health and are you engaging in any formal exercise? *

How is your mental wellbeing and stress levels? *

What are you doing to promote a positive mindset and kindness to yourself and others? *

How are any weight-related medical problems you had before surgery? e.g. diabetes, high blood pressure, joint pains, sleep apnoea etc. *

How would you rate your current efforts in trying to make positive long-lasting lifestyle changes?Please rate your effort and engagement out of 5

Our program is about helping patients to achieve better balance in their life and we will be in touch with you to advise how we might be able to help you with this issue.

Do you have any issues or concerns you would like to discuss? *

YesNo

What would you like to discuss?

These responses will be used to evaluate your progress