University of Nevada School of Medicine
Division of Bariatric Surgery
Department of Surgery
1707 W. Charleston Blvd., Suite 160
Las Vegas, NV 89102
Phone: (702) 671-5150
Fax: (702) 384-6493
BARIATRIC SURGERY PROGRAM QUESTIONNAIRE
Please complete a seven day food record prior to your appointment. Bring the food
diary to your dietary and surgical evaluations. The food diary should include:
1. amount and type of food
2. any fast food
3. all beverages
Name:____________________________________Age:__________________________
Telephone Number (work):____________________(home):_______________________
(pager/cell):________________________
Referring Physician:_________________________________________
Physician’s Address:_________________________________________
_________________________________________
_________________________________________
Physician’s Phone Number:__________________________________________
Other Physicians that care for you:___________________________________________
____________________________________________
How did you hear about us? (Internet, primary care physician, friend, etc.)
________________________________________________________________________
________________________________________________________________________
Page 1 of 9
CONSIDERING WEIGHT LOSS SURGERY
How long have you been considering weight loss surgery?
What have been your main sources of information about weight loss surgery?
Y /
Y
N
/ N
Do you know other people that have had an operation for obesity?
Have those operations been successful?
Are your family and friends supportive of your decision to undergo an operation to help
you lose weight?
What are your main reasons for considering an operation to help you lose weight?
DIET HISTORY
List the major diet programs that you have tried, including approximate dates and about
of weight lost.
Program
Date
Weight Lost
1.
2.
3.
4.
5.
6.
7.
Y
/ N
Have you used Fen/Phen in the past?
Have you used any of the following to control your weight?
Y
Y
Y
Y
Y
/
/
/
/
/
N
N
N
N
N
Bingeing and purging
Bingeing followed by food restriction
Vomiting
Laxitives
Diuretics
Page 2 of 9
WEIGHT HISTORY
What is your lifetime maximum weight? _____________________ When? _________
Y
/ N
Were you obese before puberty?
Fill out this time line of weight during your life as best as you can.
Please include any important personal events (i.e. pregnancy, marriage, etc.)
Age
0-13
13-18
18-30
30-50
50+
Maximum Weight
Important Events
CURRENT HABITS
How many carbonated beverages do you drink a day?______________ Diet/Regular
How many times a week do you eat out?__________ In a Fast Food restaurant?_______
How much water do you drink a day?_________________________________________
How much milk do you drink a day?_______________________ skim/ 1% / 2% / whole
How many cups of coffee do you drink a day?_______________ decaffeinated/regular
Do you drink alcoholic beverages? If yes, describe weekly intake.__________________
Who does the food shopping in your household?_________________________________
Who does the cooking in your household?______________________________________
How many meals a day do you eat?
Y
/ N
Do you snack throughout the day? If yes, describe.__________________
___________________________________________________________
Y
/ N
Do you eat in the middle of the night?
How many calories do you think you eat a day?_________________________________
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I feel that I am overweight because: (Check all that apply)
_____
_____
_____
_____
Y
I eat normal amounts of food but have an abnormal metabolism.
I eat larger than normal amounts of food.
I tend to eat sweets and high calorie snacks.
Other:
/ N
EXERCISE
Do you exercise regularly? If yes, describe.________________________
___________________________________________________________
If not, what is the most strenuous physical activity that you do in a week?
Which of the following activities can you do without stopping to rest?
_____
_____
_____
_____
walk to a building from a distant parking space
climb one flight of stairs
climb two flights of stairs
none of the above
If you stop to rest, what are the main reasons you stop? (check all that apply)
_____
_____
_____
_____
_____
_____
short of breath
fatigue
chest pain
joint discomfort – circle which one(s): hip
knee
ankle
back pain
other:_____________________________________________________________
SURGICAL HISTORY
List any previous operations you have had:
Operation
Date
1.
2.
3.
4.
Page 4 of 9
Problems
List any hospitalizations you have had for an illness or accident not requiring surgery:
1.
2.
3.
4.
MEDICAL HISTORY
Do you have now or have you ever had any of the following medical problems?
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Diabetes? How long?________________________________________________
Sleep apnea. How long using CPAP/BIPAP?_____________________________
Asthma
Other lung or breathing problems
Low back pain
Arthritis or degenerative joint disease
Hips
Knees
Ankles
Feet
Hypertension (high blood pressure)
Hernia (umbilical, groin, incisional)
Gallstones
Gastroesophageal reflux disease or frequent heartburn
Stress incontinence (leak urine with coughing or laughing)
Heart attack or angina (chest pain, pressure, or tightness)
Irregular heart rhythm or palpitations
Congestive heart failure
Peripheral edema (swelling of the legs or ankles)
High cholesterol
High triglycerides
Stroke
Thyroid problems
Gout
Kidney of bladder problems
Depression treated with medications and/or counseling
Anxiety
Psychiatric illness. What kind?________________________________________
History of physical or sexual abuse
Alcoholism
Substance abuse
Migraine headaches
Blood clot or embolus
Abnormal bleeding or bruising
Blood transfusion
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_____
_____
_____
_____
_____
_____
Seizure or epilepsy
Liver problems or hepatitis
Cancer
Rheumatic fever
Tuberculosis
Other (specify:)____________________________________________________
_________________________________________________________________
For women only:
Y
Y
Y
Y
/
/
/
/
N
N
N
N
Have you had problems with significant anemia?
Do you have a family history of osteoporosis?
Do you plan on becoming pregnant?
Are you post menopausal?
MEDICATIONS AND ALLERGIES
Medication
Dosage / Amount
Number of times taken
daily
1.
2.
3.
4.
5.
6.
7.
8.
9.
Y
/ N
Have you taken steroids such as prednisone or cortisone in the last 6 months?
List all medications/medical products to which you have an allergic or bad reaction?
Medication/medical product
Type of reaction
1.
2.
3.
4.
Page 6 of 9
HABITS
Have you ever smoked?
____ Never.
____ Yes, but I quit ____ years ago, and smoked about ____ packs per day for ____ years.
____ Yes, I smoke ____ packs per day and have smoked for ____ years.
Do you drink alcoholic beverages?
____ Yes, I drink more than 7 drinks weekly.
____ Yes, but I drink less than 7 drinks weekly.
____ I used to drink, but I quit. I quit ____ years ago. I used to drink _____ drinks a week
for ____ years.
____ No.
Y
/
N
Do you use recreational or illegal drugs?
Specify type:
FAMILY HISTORY
Do any of your blood relatives have the following problems?
Explain which relative(s) and type of problem in the space provided.
____ Heart disease
____ Diabetes
____ Lung Disease
____ Stroke
____ Kidney disease
____ Liver disease
____ Cancer
____ Rheumatoid arthritis
____ Alcoholism
____ Serious mental illness
Page 7 of 9
____ Other illnesses that run in the family
Y
/
N
Have you or any of your blood relatives had a serious problem with anesthesia?
Specify type:
List the approximate weights of all family members. (may also designate at normal, overweight,
or obese)
Maternal Grandmother __________
Paternal Grandmother __________
Maternal Grandfather __________
Paternal Grandfather __________
Mother __________
Father __________
Sister(s)
__________, __________, __________, __________, __________
Brother(s)
__________, __________, __________, __________, __________
Children
__________, __________, __________, __________, __________
GENERAL SYMPTOMS
Do you currently have any of the following symptoms?
____ chest pain
____ blackouts or periods of dizziness
____ palpitations or irregular heart beats
____ swelling in the ankles
____ shortness of breath when walking up one flight of stairs
____ chronic cough or sputum (phlegm) production
____ blood in your sputum
____ black or tarry stools
____ diarrhea
____ frequent or new constipation
____ temporary loss or blurring of vision
____ temporary weakness of one or more limbs
____ facial weakness or numbness
____ burning with urination or frequent urination
____ arthritis or severe joint pains
____ back pain
____ excessive bleeding following minor cuts or dental surgery
____ pregnancy
____ fever
____ weight gain or loss greater than 10 pounds in the past 3 months
Page 8 of 9
SOCIAL HISTORY
With whom do you live?
What is your occupation?
How many hours a day are you employed outside the home?
How many hours a day do you watch TV?
If you are disabled, it is because:
Could someone help care for you if you were seriously ill?
Are there people for whom you are the primary care giver?
What hobbies do you have that are important to you?
Thank you for completing this questionnaire.
It will help your doctor understand your health more thoroughly.
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