Should I consider Bariatric Surgery? Am i a candidate for weight loss surgery ?
This Obesity Questionnaire will help us determine if you are a suitable candidate for weight loss surgery. This will also guide us in planning which procedure is best for you. Please fill the details and mail this to [email protected]
PATIENT DETAILS
Name: Gender : DOB: Marital Status:
Height (Cms): ___ Present Weight (Kgs) __ BMI __
Please indicate your weight at the following times. Please indicate whether you consider your weight was below average, average, above average or very heavy in the relevant boxes.
1. Weight at beginning of high school ____
2.Weight at end of high school (15-18 years) ___
3. Weight at commencing work (21 years) ____
4.Weight at time of marriage (if applicable) ____
FOOD HISTORY:-
Indicate which foods you prefer (which foods would most likely make you go off a diet).
List any food allergies: No Known Food Allergy; Bee Sting Allergic Reaction
Do you drink juices, sweet tea, sweets or regular sodas?
Do you understand the long term changes in food intake that will be necessary after surgery for the rest of your life?
Do you understand the consequences of not complying with post –op food guidelines? How many meals you eat in a day? Do you eat between meals?
How fast do you eat? Slow / Medium / Fast
WEIGHT RELATED ILLNESS:-
Please list below all serious and hospitalization you have experienced in adulthood: Major Illness /Surgery Date and Treatment. If Yes, Please list medication and reaction.
SOCIAL HISTORY: Smoke ? Alcohol ?
Do you use any recreational drugs? ______________?_____________________
Who usually prepares the food you eat at home ?__________ ?________________
ACTIVITY LEVEL & SOCIAL INFO :-
What exercise do you do on regular basis?
How many sessions of exercise (walking, sports, etc)do you do per week for more than 30 minutes at a time Walking, Swimming
EDUCATION:
High school/ Bachelor’s degree / Master’s degree / Doctorate.
PATIENT COMMITMENT
IF YOU ARE ACCEPTED FOR SURGERY, THE FOLLOWING ARE VERY IMPORTANT TO MAINTAIN GOOD HEALTH AND TO ACHIEVE THE DESIRED WEIGHT LOSS.
Are you willing to avoid foods and beverages containing sugar?
Are you willing to never use tobacco products?
Alcohol causes gastric irritation and liver damage. After surgery, frequent alcohol consumption is unwise and can be harmful. Are you willing to have no alcohol for at least one year after surgery, and to use alcohol only on a very limited basis thereafter?
MEDICATION LIST
