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6 Month Follow Up Form |
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Name
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Please provide the full name, address and phone number of your family physician: |
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Physician Name
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Address |
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City |
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State |
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Zip |
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Phone |
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Current Weight |
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For the following questions, answer "Yes" if they occur 3 or more days a
week–otherwise answer "No". |
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Do you eat breakfast? |
Yes
No |
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Do you snack at night? |
Yes
No |
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Do you snack during the day? |
Yes
No |
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Do you drink soda or other very sugary liquids? |
Yes
No |
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Do you eat desserts and fried foods? |
Yes
No |
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Are the meals that you eat small, medium, or large as compared to normal weight
people eating the same meal? |
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How many days a week do you exercise? Answer with a number even if you have to
estimate. |
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How many cigarettes (packs) do you smoke a day? |
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Do you drink alcohol? |
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Have you been treated in an alcohol rehabilitation program? |
Yes
No |
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Do you use any recreational drugs? (“Yes” means once a month or more) |
Yes
No |
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Have you been treated in a drug rehabilitation program? |
Yes
No |
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Have you seen a psychiatrist since surgery? |
Yes
No |
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If seen by a Psychiatrist, please provide their name, address and phone number: |
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Psychiatrist Name
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Address |
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City |
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State |
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Zip |
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Phone |
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Have you been hospitalized for psychiatric reasons? |
Yes
No |
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Are you employed? |
Yes
No |
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Are you satisfied with your social life? |
Yes
No |
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With regards to your body weight, how do you now see yourself as being? |
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Using the same criteria, how do you believe that others perceive you? |
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Are you satisfied with your sex life? |
Yes
No |
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How would you rate your self esteem level now? |
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Overall, how would you rate the quality of your life as compared to before
surgery? |
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Based on how you feel now, would you have surgery again? |
Yes
No |
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Have you been diagnosed or treated for Diabetes? |
Yes
No |
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If yes, were you prescribed medication? |
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Have you been diagnosed or treated for High Blood Pressure? |
Yes
No |
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If yes, were you prescribed medication? |
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Have you been diagnosed or treated for Asthma? |
Yes
No |
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If yes, were you prescribed medication? |
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For the following questions, answer “Yes” if they occur 2 or more days a
week–otherwise answer “No”. |
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Do you have heartburn? |
Yes
No |
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Do you have swelling of ankles? |
Yes
No |
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Do you have shortness of breath after climbing one flight of stairs? |
Yes
No |
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Do you have joint pain - back? |
Yes
No |
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Do you have joint pain - hip? |
Yes
No |
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Do you have joint pain - knee? |
Yes
No |
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Do you have joint pain - ankle? |
Yes
No |
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Do you have joint pain - foot? |
Yes
No |
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Do you have restless sleep or frequent awakening? |
Yes
No |
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Do you have night sweats? |
Yes
No |
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Do you snore? |
Yes
No |
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Do you have daytime sleepiness? |
Yes
No |
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Do you have morning headaches? |
Yes
No |
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Do you lose small amounts or urine with coughing or straining? |
Yes
No |
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In the past year, has anyone told you that you held your breath for a long time
while asleep? |
Yes
No |
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Menstrual difficulties? |
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Have any other medical problems developed? |
Yes
No |
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Describe: |
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How would you rate your energy level? |
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Comments: |
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If you have filled out all of the answers to the best of your knowledge click
the Submit button below.
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printable version
