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Weight
Height  or
BMI Result kg/m2
BMI: Your Weight watch Tool

Patient Questionnaire: Patient Information: Bariatric Surgery
Full Name:
Birth Date:
Address:
Street:
City:
Zip/Postal Code
State/Province:
Country
Stats:
Current Height:
CM
Current Weight:
KG
Most you have ever weighed:
KG
Marital and parenthood Status:
Married Widowed Divorced Single (never married) 
How many years?
Do you have children: NoYes  How many?   
Do you plan to have children or have more children?  YesNo  
What type of birth control are you using presently?(if none, write NONE on the line) 
General Health Status:
Do you have any of the following (check ALL that apply)

 High Blood Pressure
 Heart Problems
 Asthma or other breathing problems
 Diabetes (high blood sugar)
 High Cholesterol
 Thyroid Disease (Hyper/Hypothyroid, Graves Disease)
 Obstructive Sleep Apnea
 Depression (treated by a mental health professional)
 Arthritis, Degenerative Joint Disease
 Polycystic Ovarian Syndrome
 Eating Disorder (anorexia, bulemia)
 GERD (Gastroesophageal Reflux Disease)
 Stomach Ulcers
Medications:
List all medications including herbal remedies, vitamins, nutritional supplements and over-the-counter drugs.
Allergies:
List all known allergies here including environmental (pollen, animal dander, etc.) food and drug
Prior Surgeries:
Please list your previous surgeries (types and dates) (example: May 1999 - laparoscopic cholecystectomy)
Other conditions:
Please list other illnesses/diseases you have or have had
Weight Loss History:
Please list the types and dates of diet programs you have tried and the amount of weight lost on each
(example: Jan-April 1999 - Weight Watchers - lost 20 kgs)
Exercise:
How many hours per week do you exercise?:
What types of exercise do you perform?:
Eating Habits:
What kinds of food do you think you eat too much of? (check ALL that apply)

 Meats     Breads/Cereals/Pastas              Soft Drinks
 Sweets    Dairy (Ice Cream/Milk/Cheese)  Junk Food
Do you snack between meals?
 YesNo  
Do you binge eat?
 YesNo  
Do you eat when you're depressed? YesNo  
 
 
 
 
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