Bariatric Questionnaire

COMPREHENSIVE BARIATRIC SURGERY ASSESSMENT

This is an electronic form you can complete on any computer, tablet or smartphone. Please complete the following questions to the best of your ability, as they form the basis of your consultation, assessment and recommendations.

Who do you live with and who are your social supports?

Do you have private health insurance for bariatric surgery? *

YesNo

Hospital Cover Level

GoldSilverBronze

Do you have to fulfil a waiting period for bariatric surgery?

YesNo

How do you plan to fund your surgery?

Private Health Insurance and I will cover out-of-pocket feesPrivate Health Insurance and I will use Early Release of Super to cover out-of-pocket feesSelf-fundingSelf-funding - early release of superMedical loan - Medipay or Total Lifestyle CreditOther

Current Height (in metres e.g. 1.72m) *PLEASE ENSURE HEIGHT IS IN METRES NOT CENTIMETRES

Current Weight (kg) *

Have you previously had any weight-loss surgery?

YesNo

How long have you struggled with your weight?

What is your heaviest weight?

What problems are your weight causing you? *

What factors do you think contributes to your weight problems? *

What have you done IN THE PAST to manage your weight? *

How much weight have you been able to lose before and how long were you able to sustain it for?

What are you CURRENTLY doing to manage your weight? *

How many regular meals a day do you usually eat?

What size portions do you usually eat for your main meals? *

How often do you eat to the point until you feel full and cannot eat anymore? If YES, please explain *

Do you ever find that you don't have control over your appetite or cravings that you unintentionally overeat in excess of what you planned to?

Do you ever turn to food, beverages, smoking or other substances when you are stressed, upset or for comfort? *

Do you drink any fizzy drinks, energy drinks, milkshakes, juice, other sweet drinks regularly?If Yes, please give details.

Please describe what you would eat for meals on a typical day

What sort of physical activity or exercise do you currently do?

Describe your sleeping pattern and quality of sleep

Do you have any of the following medical conditions?

If you have Sleep Apnoea do you use CPAP?

YesNo

Diabetes diagnosed in *

Have you ever had a blood clot in a deep vein or your lungs? *If Yes - please explain

Heart Conditions - Please list

Do you have any other medical conditions not listed already?

Do you have any mental health conditions? *

Do you get heartburn or acid reflux symptoms on a regular basis? *

No Reflux SymptomsBurning feeling behind the breastbone Stomach contents moving up to the throat or mouth (regurgitation) Pain in the middle of the upper stomach area Nausea Trouble getting a good night’s sleep because of heartburn or regurgitation Need for anti-acid medication for heartburn in addition to medication your doctor prescribed

Additional Reflux Comments

Only get reflux if I eat or drink certain thingsI don't have any reflux symptoms if I take my medicationMy reflux medication helps a littleMy reflux medication works very wellMy reflux medication doesn't seem to workI only take antiacid medication now and then when I need it

Have you had any surgery in the past? *If yes - please describe

Are you taking oral contraceptive pill, hormone replacement therapy or have an implanted contraceptive rod?

YesNo

If Yes, please list it below with your medication

Are you on any blood thinning medication?

YesNo

If Yes - please list it below with your medication

Are you on any medication for diabetes?

YesNo

If Yes - please list it below with your medication

List any medications you take (medication, dose, how often) *

What is the manifestation/reaction and the severity?

Do you smoke? *

Yes -currently. (YOU WILL NEED TO QUIT SMOKING BEFORE YOU HAVE SURGERY)NoEx-smoker

How much alcohol do you drink per week? *

Is there a procedure you are most interested in? *

Why this procedure? *

How long have you been considering surgery for? *

Do you know anyone who has had obesity surgery?

What is most important for you from having surgery?

Losing a certain amount of weightImproving medical conditions related to my weightImproving my overall healthImproving how I see myself and my self confidenceImproving my quality of lifeBecoming more active

Are there any other goals would you like to achieve from having surgery *

Would you be disappointed with surgery if you did not get to a certain weight? *

Do you have any concerns about having bariatric surgery? *

Please list any other issues or things you would like to discuss during your consultation

Signature *

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Demographics

Weight History

Eating Behaviour

Physical Activity

Sleep

Medical History

Medications

Social History

Goals of Surgery

Demographics

Weight History

Eating Behaviour

Physical Activity

Sleep

Medical History

Medications

Social History

Goals of Surgery

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