Highland Hospital / Bariatric Center / Your Journey / Healthy Lifestyle & Meal Planning / Questionnaire

Bariatric Surgery Questionnaire

This 5-part questionnaire will help us learn more about you and help us establish your best path to weight loss. The form must be completed prior to scheduling your first appointment. A printable version of this form can be found here. For questions, please call 585-341-0366.

place field "FirstName" below

Contact Information

First Name*

place field "LastName" below

Last Name*

place field "email" below

Email*

place field "Phone" below

Phone*

place field "DateofBirth" below

Date of Birth

place field "SeminarAttended" below

Have you completed a bariatric seminar?

Yes No, not yet blank

place field "DateofSeminar" below

Date of Seminar

place field "mha" below

STOP! Before completing this form please attend a Bariatric Seminar.

The first step in your weight loss journey will be to complete or schedule to attend a bariatric seminar. This comprehensive seminar will provide you with all the information you'll need in the weeks and months ahead.

Part 1: Medical History

Please check condition that applies to you:

Have you ever had surgery?

Yes No blank

place field "sha" below

Select any surgery that applies to you:

What type of Bariatric Surgery did you have?

Sleeve Gastrectomy Duodenal Switch Gastric Bypass Lap Band Other

place field "FH_Anesthesia" below

Indicate any known family history:

Part 2: Social History

Do you drink alcohol?

Yes No blank

place field "Wine" below

Please indicate the amount you drink each week:

Wine (glasses per week)

place field "Beer" below

Beer (cans per week)

place field "Shots" below

Liquor (shots per week)

place field "Commentsonalcoholuse" below

Comments on alcohol use

place field "drugusage" below

Do you currently use illicit/street drugs?

Yes No blank

place field "Cocaine" below

How many times/week?

Cocaine

place field "Methamphetamines" below

Methamphetamines

place field "Inhalants" below

Inhalants

place field "IV" below

place field "DateDruguse" below

Date last used:

place field "CommentsDruguse" below

Comments on drug use

place field "consumestobacco" below

Do you use tobacco products?

Yes In the past No blank

place field "smokeless" below

place field "TobaccoComments" below

Comments on your history with tobacco

place field "QuitDate" below

Quit Date

place field "SexuallyActive" below

Sexually Active?

Yes No Not Currently blank

place field "BirthControl" below

Part 3: Medications, Vitamins, & Allergies

Do you take any medications or vitamins?

Yes No blank

place field "med1name" below

Please list below all Medications and Vitamins you are currently taking. Ex. Lipitor, 10mg, one tablet daily at bedtime

Name	Dose	Frequency
place field "med1dose" below	place field "med1freq" below	place field "med2name" below
place field "med2dose" below	place field "med2freq" below	place field "med3name" below
place field "med3dose" below	place field "med3freq" below	place field "med4name" below
place field "med4dose" below	place field "med4freq" below	place field "med5name" below
place field "med5dose" below	place field "med5freq" below	place field "med6name" below
place field "med6dose" below	place field "med6freq" below	place field "med7name" below
place field "med7dose" below	place field "med7freq" below	place field "med8name" below
place field "med8dose" below	place field "med8freq" below	place field "med9name" below
place field "med9dose" below	place field "med9freq" below	place field "med10name" below
place field "med10dose" below	place field "med10freq" below	place field "Allergy1name" below

Please list any allergies and reactions you may have

Allergy	Reaction
place field "Allergy1reaction" below	place field "Allergy2name" below
place field "Allergy2reaction" below	place field "Allergy3name" below
place field "Allergy3reaction" below	place field "Allergy4name" below
place field "Allergy4reaction" below	place field "Allergy5name" below
place field "Allergy5reaction" below	place field "Sittingreading" below

Part 4: Sleep Assessment

Answer the following questions based on your current sleep situation.

How likely are you to doze off in these situations?

Situation	Chance of Dozing
Sitting and reading	Sitting and reading place field "WatchingTV" below
Watching TV	Watching TV place field "PublicPlace" below
Sitting, inactive in a public place (ex. in a movie theater or a meeting)	Sitting, inactive in a public place (ex. in a movie theater or a meeting) place field "CarPassenger" below
As a passenger in a car for an hour or more	As a passenger in a car for an hour or more place field "Lyingdown" below
Lying down to rest in the afternoon	Lying down to rest in the afternoon place field "SittingTalking" below
Sitting and talking	Sitting and talking place field "SittingQuietly" below
Sitting quietly after lunch (without alcohol consumption)	Sitting quietly after lunch (without alcohol consumption) place field "DrivingaCar" below
While driving a car, while stopped for a few minutes in traffic	How likely are you to dose off while driving a car, while stopped for a few minutes in traffic place field "Snoring" below

How frequently do you snore or have you been told you snore loud enough to disturb other’s sleep?

Never Rarely- less than once a week Occasionally- 1-3 times a week Frequently- More than 3 times a week Unsure

place field "StopBreathing" below

How often have you been told you pause or stop breathing while sleeping?

Never Rarely- less than once a week Occasionally- 1-3 times a week Frequently- More than 3 times a week Unsure

place field "DaySleep" below

Do you sleep during the day?

Yes No

place field "ExsessiveSleep" below

Do you sleep excessively?

Yes No

place field "Obese5Years" below

Part 5: Weight Loss History

Have you been morbidly obese for more than 5 years?

Yes No

place field "ObeseInChildhood" below

Have you been obese since childhood?

Yes No

place field "ObeseSincePregnant" below

Have you been obese since pregnancy?

Yes No

place field "haswlmeds" below

What diet programs have you tried?

Only document your weight loss attempts in the past 5 years

Diet Program	Number of Months	Weight lost	Physician Supervised?	Year
Atkins	place field "atlost" below	place field "atdr" below	place field "atyr" below	place field "jcmonths" below
Jenny Craig	place field "jclost" below	place field "jcdr" below	place field "jcyr" below	place field "lamonths" below
LA Weight Loss	place field "lalost" below	place field "ladr" below	place field "layr" below	place field "nsmonths" below
Nutri-System	place field "nslost" below	place field "nsdr" below	place field "nsyr" below	place field "wwmonths" below
Weight Watchers	place field "wwlost" below	place field "wwdr" below	place field "wwyr" below	place field "sbmonths" below
South Beach	place field "sblost" below	place field "sbdr" below	place field "sbyr" below	place field "rdmonths" below
Registered Dietitian	place field "rdlost" below	place field "rddr" below	place field "rdyr" below	place field "ommonths" below
Optifast/ Medifast	place field "omlost" below	place field "omdr" below	place field "omyr" below	place field "ccmonths" below
Calorie Controlled	place field "cclost" below	place field "ccdr" below	place field "ccyr" below	place field "OtherDiets" below

Please list any other diets you have tried in the last 5 years

You have reached the end of the questionnaire, please click submit to take the next steps in your journey.

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Bariatric Surgery Questionnaire

Contact Information

STOP! Before completing this form please attend a Bariatric Seminar.

Part 1: Medical History

Part 2: Social History

Part 3: Medications, Vitamins, & Allergies

Part 4: Sleep Assessment

How likely are you to doze off in these situations?

Part 5: Weight Loss History

Tell us about your previous weight loss attempts:

What diet programs have you tried?