Angeles Health Bariatric Treatment Questionnaire

Patient Name:*   Procedure Date: Email Address:* Date of Birth: Gender: Male Female Weight: Height: Body Mass Index: Emergency Contact: Relationship: Children: Marital Status: Primary Doctor: Primary Dr Phone: Primary Dr address:		Address* Street:* City:* State/Province:* Country: Zip/Postcode:* Office Phone: Mobile Phone: Home Phone:* Work Phone: Referring Doctor: Referral Dr Phone:

Employment

Question	Responses
Are you currently employed?	Yes No
If you are unemployed, what is the reason?
Are you actively looking for work?	Yes No
Has your weight made it difficult to find employment?	Yes No

Do you have a family history of any of the following and if so, please indicate

Question	Responses
Diabetes	Parent Siblingl/Child Other Relatives Don't Know No History
Heart Disease	Parent Siblingl/Child Other Relatives Don't Know No History
Hypertension	Parent Siblingl/Child Other Relatives Don't Know No History
Gout	Parent Siblingl/Child Other Relatives Don't Know No History
Gallstones	Parent Siblingl/Child Other Relatives Don't Know No History
Obesity	Parent Siblingl/Child Other Relatives Don't Know No History
Snoring/Sleep Apnea	Parent Siblingl/Child Other Relatives Don't Know No History
Asthma	Parent Siblingl/Child Other Relatives Don't Know No History
Allergies	Parent Siblingl/Child Other Relatives Don't Know No History
Hayfever	Parent Siblingl/Child Other Relatives Don't Know No History
Dermatitis/Eczema	Parent Siblingl/Child Other Relatives Don't Know No History
High Cholesterol	Parent Siblingl/Child Other Relatives Don't Know No History
Osteoporosis	Parent Siblingl/Child Other Relatives Don't Know No History
Hip Fractures	Parent Siblingl/Child Other Relatives Don't Know No History

Please indicate your weight at the following times. Please indicate whether your weight was below average, average, above average or very heavy. Current Weight and BMI are indicate in the Summary on top of the Profile!

Question	Responses
Birth Weight	Select Below Average Average Above Average Heavy
Weight at age 10-12	Select Below Average Average Above Average Heavy
Weight at age 15-18	Select Below Average Average Above Average Heavy
Weight at age 21	Select Below Average Average Above Average Heavy
Weight at time of marriage (if applicable)	Select Below Average Average Above Average Heavy

Current Weight and Lifestyle

Question	Responses
How would you describe your body shape:	Select Apple Pear Athletic Hourglass Slender Inverted Triangle Tall Petite
Current waist size:
Current hip size:
How many years have you been overweight?
Weight trend in the last 6 months:
Exercise habits:
Eating Habits: How many meals per day, snacking between meals, binge eating, sweets, fast food soda:
Drug use (currently and in the past):	Yes No
Psychiatric Disorders (currently and in the past), when was the diagnosis made?	Yes No
Hospitalization for psychiatric disorders?	Yes No

Dieting and Weight Loss History

Question	Responses
Weight Watchers
Duration
Fad Diets
Appetite Suppressants
Details of any other weight loss measures (including surgical)
Where there any particular events that lead to significant weight gain?

Question: Have you ever suffered from any of the following health problems? If yes, please provide details such as dates, diagnosis, and duration of illness. NOTE: If no details are provided the question will not appear.

Question	Responses
Diabetes	Yes No
Diabetes Details
Diabetes while pregnant	Yes No
Arthritis or Joint Pain	Yes No
Back Pain	Yes No
Kidney or Urinary Disorder	Yes No
Neurological	Yes No
Psychological/Nervous Disorder	Yes No
Gallstones	Yes No
Gastric or Duodenal Ulcer	Yes No
Hepatitis or Liver Disease	Yes No
High Blood pressure	Yes No
High Blood pressure Details
Heart Disease	Yes No
High Cholesterol	Yes No
High Cholesterol Details
Anemia or Bleeding Disorder	Yes No
Thrombosis or Clotting Disorder	Yes No
Varicose Veins or Leg Swelling	Yes No
Eczema or Skin Condition	Yes No
Hay fever or Rhinitis	Yes No
Allergies	Yes No
Surgical History
Major Illnesses
Medication - psychiatric	Yes No
Medication - psychiatric details
Medication - migraine	Yes No
Medication - weight loss	Yes No
Medication - epilepsy	Yes No
Medication - asthma	Yes No
Medication - hormones	Yes No
Medication - HRT	Yes No
Medication - cortisone	Yes No
Medication - last 12 months	Yes No

Surgical History

Question	Responses
Please give details of any past operations:

Allergies

Question	Responses
Allergies (including foods, medications, dressings)

Question: Please indicate whether you are now or have previously taken any of the following medications. If yes, please state the name of the medication and how long you have been or were taking it.

Question	Responses
Medication for psychiatric disorder	Yes No
Migraine medication	Yes No
Medications to assist weight loss	Yes No
Drugs for epilepsy	Yes No
Drugs for asthma or breathing	Yes No
Hormones, e.g.The Pill	Yes No
HRT	Yes No
Cortisone	Yes No
Please list in detail all medications that you have used in the last 12 months. Please include any dietary supplements, creams, eye drops, etc.
What medications are you currently taking?

Lifestyle

Question	Responses
Please include your main daily routines and describe your main social/familiar environment. Example: Jeff 44 Patient requesting surgery. Wife Anna 36. Three biological children: Kevin 16, Pamela 14. They live with their mom and visit on vacation. Stephen 7. Work: office manager. Sedentary job. Working hours: Mon -Sat 9 to 6. Have an hour lunch break. Excercise: hiking only every other weekend. Recreational activities: eating out with family, taking Stephen to playground or the movies. Some nights beer with friends.
What do I want to get out of this weight loss surgery besides losing weight?
Why am I choosing this surgery over the other ones?

Sleep History

Question	Responses
On average, how many hours of sleep do you get a night?
Is there anything that keeps you awake at night?	Yes No

NOTE: The answers are rated from Never to Always with never being 0 and always being 5

Question	Responses
How often do you snore?	Select Never Sometimes Athletic Often Mostly Always
Do you wake during the night with a choking feeling?	Select Never Sometimes Athletic Often Mostly Always
How often do you snore?	Select Never Sometimes Athletic Often Mostly Always
How often would you sleep more than 8 hours in total in a 24 hour period?	Select Never Sometimes Athletic Often Mostly Always
Do you feel sleepy during the day?	Select Never Sometimes Athletic Often Mostly Always
Has anyone noticed that you momentarily stop breathing during your sleep?	Select Never Sometimes Athletic Often Mostly Always
How often do you doze off or fall asleep while driving?	Select Never Sometimes Athletic Often Mostly Always
How often do you wake up more than once during the night?	Select Never Sometimes Athletic Often Mostly Always
Do you have a headache when you wake up in the morning?	Select Never Sometimes Athletic Often Mostly Always
Do you fall asleep while reading?	Select Never Sometimes Athletic Often Mostly Always
Do you wake up in the morning feeling confused?	Select Never Sometimes Athletic Often Mostly Always
How often do you have a nap during the day?	Select Never Sometimes Athletic Often Mostly Always
Have you or anyone else noticed a change in your personality recently?	Select Never Sometimes Athletic Often Mostly Always
Do you feel sleepy in the evenings?	Select Never Sometimes Athletic Often Mostly Always

NOTE: The answers here are rated from no chance to slight chance to moderate chance to high chance

Question	Responses
Sitting and reading	Select No Chance Slight Chance Moderate Chance High Chance
Watching TV	Select No Chance Slight Chance Moderate Chance High Chance
Sitting inactive in a public place (e.g. theatre or meeting)	Select No Chance Slight Chance Moderate Chance High Chance
As a passenger in a car for an hour without a break	Select No Chance Slight Chance Moderate Chance High Chance
Lying down to rest in the afternoon when circumstances permit	Select No Chance Slight Chance Moderate Chance High Chance
Sitting and talking to someone	Select No Chance Slight Chance Moderate Chance High Chance
Sitting quietly after a lunch without alcohol	Select No Chance Slight Chance Moderate Chance High Chance
In a car, while stopped for a few minutes in traffic	Select No Chance Slight Chance Moderate Chance High Chance

Activity Level

Question	Responses
How many sessions of exercise (walking, sports, etc) do you do per week for more than 30 minutes at a time?
What sort of activities?
How do you feel when exercising? Use a scale of 1-10, where 1 is awful and 10 is excellent.

Smoking & Alcohol

Question	Responses
Do you drink	Yes No
Do you currently smoke?	Yes No
Have you smoked in the past?	Yes No
If yes, how many per day?
For how many years
When did you stop smoking?
Do you drink any alcohol?	Yes No
How often do you have a drink containing alcohol?
What is the main alcoholic beverage you drink? (choose one)	Select Wine Beer Spirits
What others do you drink occasionally? (choose all that apply)	Select Wine Beer Spirits
When do you mainly drink? (choose one)	Select Wine Beer Spirits
At what other occasions do you drink? (choose all that apply)	Select Wine Beer Spirits

Breathing History and Asthma

Question	Responses
Asthma	Yes No
Respiratory/Breathing Problems	Yes No
Does being at work ever make your chest tight or wheezy?	Yes No
Have you ever had asthma?	Yes No
Have you ever had to change a job because it affected your breathing?	Yes No
Have you ever worked in a job which exposed you to vapors, gas, dust, or fumes?	Yes No
Have you ever had to spend a night in hospital because of asthma/breathing problems?	Yes No
If yes, was it in the last 12 months?	Yes No
In the last 12 months, have you visited an emergency room or seen a doctor urgently because you had asthma or breathing problems?	Yes No
In the last 12 months, have you taken a course of Prednisolone because of asthma or breathing problems?	Yes No
In the last 12 months, have you missed work or school because of asthma or breathing problems?	Yes No
Do you usually have a cough?	Yes No
Do you usually bring up phlegm from your chest when you cough?	Yes No
Do you get short of breath on exertion?	Yes No
Do you get short of breath walking on flat ground?	Yes No
Do you get short of breath walking uphill or doing housework?	Yes No
In the last 12 months, have you had an attack of shortness of breath that came on when you were not exerting yourself and without obvious cause?	Yes No
In the last 12 months, have you had wheezing in your chest?	Yes No
In the last 12 months, have you had an attack of wheezing that came on after you stopped exercising?	Yes No
In the last 12 months, have you had a feeling of tightness in your chest on waking in the morning?	Yes No

Gastroesphageal Reflux Indigestion

Question	Responses
Reflux or Heartburn	Yes No
Do you have a history of heartburn or indigestion?	Yes No
Details
If yes, how often do you have reflux during the day?
Do you suffer heart burn or indigestion during the night? If so, how often?
What aggravates or causes your reflux?
Do you have difficulty swallowing?	Yes No
Does food ever get stuck?	Yes No
Does food or fluid reflux into the mouth?	Yes No
Do you vomit with reflux?	Yes No
Do you suffer from recurrent sore throats?	Yes No
Do you suffer from a hoarse voice?	Yes No
Do you suffer from a regular cough at night?	Yes No
Please list any treatments you may use for reflux / heartburn or indigestion

Dietary Supplements

Question	Responses
Do you take multivitamin tablets or other dietary supplements?	Yes No
Do you take folate tablets?	Yes No

Ladies

Question	Responses
Do you have regular periods (26 - 33 days)?	Yes No
If not, please describe
Do you have problems with excessively heavy periods?	Yes No
Have you had difficulty in conceiving in the past?	Yes No
Do you currently have problems with infertility?	Yes No
Have you suffered from excess body hair or acne?	Yes No
Have you ever been told by a doctor that you have polycystic ovaries?	Yes No
Have you had problems with pregnancy and/or childbirth?	Yes No
Have you had a caesarean section?	Yes No
If yes, why?
Have you noticed a reduction in your libido or sex drive?	Yes No