Confidential
Bariatric Regional Assessment & Treatment Centre Health Sciences North/Horizon Santé-Nord Sudbury Outpatient Centre 865 Regent St. South, Main Floor, Sudbury, ON P3E 3Y9 Telephone: 705-671-5611 Fax: 705-671-5635
Dear Primary Care Provider:
On behalf of Health Sciences North, we would like to welcome you to our Bariatric Surgical Program. You are receiving this package because we have received your referral for the following patient:
Patient Name: ______Date of Birth: ______
As a primary care provider, you are an integral part of our team. In order to prevent unnecessary delays to determine if your patient qualifies for bariatric surgery, we kindly request that you:
Complete Physical Exam within the past year
Initial baseline fasting Blood Work (Appendix A) completed
Sleep Study ordered if Stop-Bang ≥3/8 ** Patients requiring sleep studies often face long delays, therefore, please screen your patient for sleep apnea using the enclosed STOP- BANG questionnaire and arrange for a sleep study if score is ≥3. Please indicate BARIATRIC PATIENT on the requisition.
If h.pylori POSITIVE, please treat and confirm eradication with C14/C13 Urea Breath Test 6 weeks post-treatment
If any heart disease, include cardiac clearance
Please include any gastroscopy/colonoscopy, abdominal ultrasounds, CXR, cardiac testing, pulmonary function tests or sleep studies that may have been completed within the past year and mail/fax to the address below
Forward to Bariatric Program
Once this information is received, along with the patients’ questionnaire, they will be invited to an initial orientation session. They will then be booked to see some/all members of our multidisciplinary team to determine suitability for bariatric surgery.
Please note: The questionnaire must be mailed or faxed to the Sudbury Bariatric Regional Assessment and Treatment Centre at the address above no later than 12 weeks from the date it was received.
Thank you for your attention to this matter.
Sincerely, The Bariatric Team
Toll free sans Frais www.hsnsudbury.ca 1.866.469.0822
Sudbury Regional Assessment & Treatment Centre Questionnaire for Primary Care Provider
Please complete the following information within one month of receiving and fax to 705-671-5635
PRIMARY CARE PROVIDER INFORMATION
Name: ______Practice: MD NP Specialist
Contact Number: ______Fax Number: ______
Address: ______
PATIENT INFORMATION
Last Name: ______First Name: ______
Date of Birth: ______
CONTRAINDICATIONS TO SURGERY
General
Unable to provide informed consent Yes No Unable to follow post-operative instructions Yes No
Within Last Year
Actively suicidal Yes No Active Bulimia Nervosa (includes purging) Yes No Mental health hospitalization Yes No Medical risk too great Yes No
Medication consideration: Patients who are NSAID dependent or on sustained release medications absolutely necessary to treat an illness which the surgery is unlikely to resolve and for which there are no therapeutic alternatives are relatively contraindicated.
If you have answered YES to any of the above contraindications, your patient is NOT a surgical candidate at this time
1
Sudbury Regional Assessment & Treatment Centre Questionnaire for Primary Care Provider
Obesity Related Concerns
If any heart disease, include cardiac clearance Venous Stasis Ulcers Kidney Stones CPAP Dysmenorrhea Sleep Test Ordered (STOP BANG ≥3) Infertility Other ______ Polycystic Ovarian Syndrome
Endocrine Disorders That May Cause Morbid Obesity
Hypothyroidism Clinical suspicion of Cushing’s disease Iatrogenic Cushing’s disease (long term steroid use)
Previous Weight Loss Surgery
No Yes, type of surgery and year: ______
The referred patient understands that weight loss surgery is a life altering event. To be successful all candidates must be committed to lifelong lifestyle changes. As the referring provider, I understand that weight loss surgery requires lifelong monitoring for nutritional deficiency. These nutritional deficiencies are common after gastric bypass surgery and long term monitoring and replacement are the responsibility of the referring provider for as long as the patient is under your care.
Provider Signature: ______Date: ______
Thank you for your assistance. If you have any questions or concerns, please call us! Sudbury Bariatric Regional Assessment & Treatment Centre 705-671-5611
Please indicate that you have read that the Shared Care Model is outlined by the Ontario Bariatric Network as follows:
“The Shared Care Model for the OBN Surgical Program involves a partnership between our bariatric centres and patients’ primary care providers (PCPs) to provide the necessary medical care to patients during the post-operative period. Complete care is then transitioned to PCPs at 1 year after surgery with bariatric centre involvement only as needed.”
2
Sudbury Regional Assessment & Treatment Centre Appendix A: Laboratory Request Form
Below is the list of blood work required by the OBN registry pre-operative phase of the program. Once all blood work is complete, please fax us a copy of the results to Fax # 705-671-5635. If you have any questions or concerns please contact our office.
REQUIRED PRE-OP LABS ORDERED Fasting Blood Glucose HbA1C CBC Electrolytes: Na, K, Cl Calcium Phosphorus Creatinine Lipid Profile: Chol, TG, LDL, HDL, Chol/HDL ratio TSH PTH Albumin AST ALT Alkaline phosphatase Bilirubin Vitamin D25 Vitamin B12 Ferritin Urine albumin/creatinine ratio – only if IFG/DM Helicobacter Pylori (PHL req) Pregnancy test for women of childbearing age
1. Vitamin D testing is OHIP-insured where it is known that a malabsorption state will occur such as roux-en-y gastric bypass surgery (MOHLTC InfoBulletin #4522, Nov 2010).
2. Please note that Manitoulin Health Centre no longer performs vitamin testing. Your patients may opt to use an alternate lab to avoid having to return for a second venipuncture as these are OBN required pre- operative investigations.
Toll free / Sans frais www.hsnsudbury.ca 1.866.469.0822 STOP-BANG Questionnaire
Today’s Date:
Patient Name: Sex: Date of birth (mm/dd/yyyy):
Address: City: State: Zip:
Insurance (primary): Policy #:
Please answer the 8 questions below to help us assess for possible sleep apnea, a condition in which your breathing pauses or stops for periods of time while you sleep. Sleep apnea can increase your risk for many health conditions. It can also increase your risk for breathing problems after surgery. If you are at risk for sleep apnea, your surgeon may ask that you be evaluated by a sleep physician prior to any surgery. This is for your own safety. NOTE: If you already have a diagnosis of sleep apnea, you do not need to complete this questionnaire. However, if you are having surgery, it is important that you let your surgeon and anesthesiologist know that you have this diagnosis. You will also need to bring your CPAP machine to the procedure for use before and after your surgery while sleeping.
YES NO 1. Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? 2. Tiredness/fatigue: Do you often feel tired, fatigued, or sleepy during the daytime, even after a “good” night’s sleep? 3. Observed apnea: Has anyone has ever observed you stop breathing during your sleep?
4. Pressure: Do you have or are you being treated for Height Weight (lb) Height Weight (lb) high blood pressure? 4’10” 167 5’8” 230 5. Body mass index: Do you weigh more for your height 4’11” 173 5’9” 237 than is shown in the tables at right? 5’ 179 5’10” 243 5’1” 185 5’11” 250 ge: 6. A Are you older than 50 years? 5’2” 191 6’ 258 7. Neck size: Does your neck measure more than 5’3” 197 6’1” 265 15¾ inches (40 cm) around? 5’4” 204 6’2” 272 5’5” 210 6’3” 279 8. Gender: Are you male? 5’6” 216 6’4” 287 5’7” 223 6’5” 295 Weights shown in the tables above correspond to a BMI of 35 for a given height.
STOP-BANG QUESTIONNAIRE Questionnaire adapted with permission from Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, Khajehdehi A, Shapiro CM. Anesthesiology. 2008; 108(5):812-821. CPM031b - 04/23/10 Patient and Provider Publications 801.442.2963
Sudbury Bariatric Regional Assessment & Treatment Centre
CONSENT TO THE DISCLOSURE OF PERSONAL HEALTH INFORMATION
I, ______, (Please print your name) of ______, (Address) give my informed consent to:
______(Agency)
______(Address)
in order to disclose and share personal health information with the Sudbury Bariatric Regional Assessment & Treatment Centre for the purposes of assessing for suitability for bariatric surgery.
The following can be shared:
Emotional health related strengths and concerns Mental health related strengths and concerns Other ______
I understand the purpose for disclosing this personal health information as noted above. This consent form will be considered valid from:
______to ______Patient Signature Start date End date
Witness Name (Please Print): ______
Relationship to Patient: ______
Signature: ______Date: ______
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
Please complete this questionnaire fully with as much detail as you can provide. Incomplete questionnaires will be sent back to you which may cause a delay.
Indicate which program you are interested in: Surgical Medical (Optifast®)
DEMOGRAPHIC INFORMATON
Last Name: ______First Name: ______Initial: _____
Gender: Male Female Self-identify as ______
Date of Birth: ______Age: ______
Ethnicity: ______Primary Language: ______
HEALTH CARE PROVIDER INFORMATION
Family Doctor/Primary Care Provider: ______
Phone Number: ______Fax Number: ______
Psychiatrist: Yes No Name: ______
Phone Number: ______Fax Number: ______
PHARMACY INFORMATION
Home Pharmacy Name: ______
Phone Number: ______Fax Number: ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
ALLERGIES (DRUG/FOOD/ENVIRONMENTAL)
ALLERGIES REACTION
MEDICATION HISTORY
Make sure you include vitamins, herbs, natural products, puffers and any over the counter medications. If possible attach a pharmacy list.
MEDICATION DOSAGE HOW OFTEN FOR WHAT CONDITION
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
SUBSTANCE USE
SMOKING (including cigarettes, cigars, e-cigarettes, chewing tobacco, etc.) NO YES - If yes, what? ______ Previously Quit Date: ______
MARIJUANA USE NO YES - How much per week? ______If yes, how are you using it? Smoking Vaping Edible Do you have a license? NO YES - If yes, please provide a copy of your license to us when you attend your initial assessment Previously Quit Date: ______
DRUG USE NO YES - How much per week? ______Which drugs? ______ Previously Quit Date: ______
ALCOHOL USE NO YES - How many drinks per week? ______Type of Alcohol: ______ Previously Quit Date: ______
TREATMENT PROGRAM
Have you ever participated in a drug and/or alcohol addiction program? NO YES If Yes: Where? ______When? ______Was treatment completed? No Yes If No, why? ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
MEDICAL HISTORY
Do you currently have, or have you ever had any of the following conditions?
CARDIOVASCULAR DISORDERS Condition Yes No Comments/Details High Blood Pressure High Cholesterol Heart Failure Heart Attack When? Angina Pacemaker Internal Cardiac Defibrillator Blood Clot in Lungs Blood Clot in Legs Varicose Veins Peripheral Vascular Disease Other:
Have you ever had?
A stress/treadmill test? Yes No If Yes, when? ______A chemical stress test (MIBI scan)? Yes No If Yes, when? ______An angiogram (dye test)? Yes No If Yes, when? ______An angioplasty/stent? Yes No If Yes, when? ______Have you ever seen a cardiologist? Yes No If Yes, when? ______If yes, what is the name of your cardiologist? ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
ENDOCRINE DISORDERS Condition Yes No Comments/Details Diabetes Type 1 Type 2 Pre-Diabetic Any complications? Yes No Explain:
Thyroid Disease Hypothyroid (underactive) Hyperthyroid (overactive) Other:
RESPIRATORY DISORDERS Condition Yes No Comments/Details Sleep Apnea Do you use CPAP? Yes No Do you use BIPAP? Yes No Asthma Bronchitis Emphysema Pneumonia Chronic Obstructive Pulmonary Disease (COPD) Lung Cancer Treatment Dates: Other:
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
MUSCULOSKELETAL DISORDERS Condition Yes No Comments/Details Osteoarthritis Diagnosed Joints Affected: Fibromyalgia Diagnosed Restless Leg Syndrome Diagnosed Other:
SKIN/TISSUE DISORDERS Condition Yes No Comments/Details Skin Cancer Where? Cellulitis Where? Rashes Where? Psoriasis Where? Eczema Where? Other: Where?
NEUROLOGIC DISORDERS Condition Yes No Comments/Details Frequent Headaches Migraines Vertigo Stroke/TIA Epilepsy Seizures Intracranial Hypertension Other:
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
GENITOURINARY DISORDERS Condition Yes No Comments/Details Kidney Stones When? Kidney Failure Kidney/Bladder Cancer Last treatment date: Prostate Cancer Erectile Dysfunction Urinary Stress Incontinence (spill urine when coughing, etc.) Polycystic Ovary Syndrome Gout Ovarian Cancer Last treatment date: Uterine Cancer Last treatment date: Cervical Cancer Last treatment date: Breast Cancer Last treatment date: Infertility Other:
GASTROINTESTINAL DISORDERS Condition Yes No Comments/Details Heartburn (GERD) Diagnosed Gallstones Hernia Type: Ulcerative Colitis Crohn’s Disease Irritable Bowel Syndrome Cirrhosis/Liver disease Ulcers Stomach Duodenal Other Pancreatitis Stomach/Colon Cancer Other:
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
BLOOD RELATED DISORDERS Condition Yes No Comments/Details Blood Transfusion When? Anemia Hemophilia Leukemia Lymphoma Other:
COMMUNICABLE DISEASES Yes No Comment: ______
SURGICAL HISTORY
Please list any operations you have had. Please include whether the operation was OPEN (large incision) or LAPARASCOPIC (a few small ½ - 1 inch incisions).
Surgery Date Open Laparoscopic Comments
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
History of Anesthetic problems: Yes No
If yes, explain: ______
DENTAL/VISION Condition Yes No Comments/Details Difficulty swallowing Difficulty chewing Difficulty with vision Wear glasses Other:
FOR WOMEN ONLY
Number of Pregnancies Number of Children Last Menstrual Period Date: Duration (how many days): Describe flow: Light Moderate Heavy Menopausal No Yes Last Pap Test Date: Mammogram No Yes Date:
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
FAMILY MEDICAL HISTORY
Please place a check mark in all boxes that apply. Unknown Family History Grandparents Parents Siblings Obesity Diabetes Heart Disease Hypertension High Cholesterol Stroke COPD Asthma Cancer Mental Illness Cohn’s Colitis Bleeding Disorder Other:
PHYSICAL ACTIVITY
Are you presently physically active or exercising? (Do not include the activity you routinely do at work or at home).
YES What type of exercise? ______
How many times per week? ______How many minutes per day? ______
NO
Reason? ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
WEIGHT LOSS ATTEMPTS
How long have you been overweight? ______
Your heaviest adult weight (18 yrs. or older)? ______Age: ______
Your lightest adult weight (18 yrs. or older)? ______Age: ______
What methods have you used to lose weight in the past and when? Check all that apply
Self-directed diets (i.e., low carb, low fat, fad diets, calorie restricted, etc.) When? ____
Doctor Supervised Diets When? ______
Dietitian Supervised Diets When? ______
Pills/Supplements When? ______
Weight Loss Clinics (i.e., Weight Watcher’s) When? ______
Injections When? ______
Hypnosis When? ______
Other: ______
Have you had any success with your weight loss with these methods? ______
What was it that made that method helpful? ______
What factors led to weight regain? ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
List 3 problems you encounter in your daily life because of your current body weight. ______DIET HISTORY
How many times per week do you consume meals made from outside of the home (i.e. take-out, cafeteria, restaurant, etc.)? ______
Where do you eat? ______
Do you skip meals? Never Seldom Occasionally Frequently
If you skip meals; which meals do you skip: ______
Do you over eat? Yes No
If yes, how much food and how often? ______
Do you have an eating disorder? Yes No Suspected or Diagnosed
What type? Anorexia Nervosa – deliberate self-starvation, intense fear of gaining weight, highly restrictive eating, compulsive dieting, and/or excessive exercising
Bulimia Nervosa – pre-occupation with food, binge eating in secret, vomiting after bingeing, abuse of laxatives, diuretics, diet pills, compulsive exercise
Binge Eating – loss of control over amount of eating, marked distress over binge episode, occurs at least once per week for 3 months AND, THREE or more of the following: o eating more rapidly than normal, eating until uncomfortably full, o eating large amounts of food when not physically hungry, o eating alone due to embarrassment over how much one is eating, o feeling disgusted, depressed or very guilty with oneself after bingeing Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
Have you ever participated in an eating disorder treatment program? Yes No
If so, when and where? ______
Have you made any improvements or positive changes in your food choices in the last 6 months? ______
Which of the following beverages do you drink and how much on average? Check all that apply
Item None How Much? Coffee, caffeinated Coffee, decaffeinated Tea, caffeinated Tea, decaffeinated Juice Diet juices/drinks Lemonade or Iced Tea Regular pop Diet pop Smoothies Milk % Water
PSYCHOSOCIAL
Type of housing: Own Rent Other ______
Who lives with you presently? ______
Your present relationship status:
Single Married Common-law Divorced Separated Widowed
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
Please describe your current relationship: ______
Please provide details of past significant relationships (marriages/common-law/dating, length of relationship, when/why it ended, positives/challenges in relationship): ______
Your children/step-children/foster children: Name Age Where do they live Present Concerns
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
FAMILY HISTORY
Where were you born: ______Where did you grow up: ______Age you left home: ______Why? ______Where did you go? ______Mother’s first name: ______Alive/Deceased (circle one) Age: ______Describe your relationship: ______Father’s first name: ______Alive/Deceased (circle one) Age: ______Describe your relationship: ______List the first names of your siblings/step-siblings/foster siblings: Name Age Where do they live Relationship with them
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
Describe your childhood overall (positives/challenges): ______
Was there any type of abuse in the environment that you were raised in? YES NO Alcohol Drug Physical Emotional/Verbal Sexual Neglect Extreme Poverty To maintain privacy, any details will be discussed during your assessment. How was food used in the environment that your were raised in: (3 meals a day; eat what is on your plate; sit down family meals; celebrations; eating for comfort; very little food available, etc.) ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
EDUCATION
What is the highest level of education you have completed? ______Where: ______Year completed: ______Program: ______Challenges: ______Are you in school now? Yes No Where: ______Program: ______Expected completion date: ______
CURRENT STATUS, ENVIRONMENT AND DAILY ROUTINE
Occupational status: Full-time Part-time Unemployed Retired Student Ontario Works Disability (ODSP, WSIB, LT disability, Other) Your current job title: ______Employer: ______Length of time at that job: ______Hours of work: ______Days you work: ______Do you have benefits: ______Are you able to take sick leave: ______Do you have an Employee Assistance Program (EAP)? ______Your job history: ______Your partner’s job: ______List all present sources of income: ______Current financial problems (be specific): ______Are you able to afford the costs associated with participating in the desired program? YES NO If no, why not? ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
Current legal problems (be specific): ______
Are you planning any major life changes (i.e., new job, retirement, moving, relationship, etc.) during the next year? Yes No ______
Please describe your usual daily routine:
Usually awake at ______AM Breakfast at ______AM Morning routine: ______Snack at ______AM Lunch at ______PM Afternoon routine: ______Snack at ______PM Supper at ______PM Evening routine: ______Usually asleep at ______PM/AM
Additional comments about your daily schedule: ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
MENTAL HEALTH
Have you ever been diagnosed with a mental health concern (please describe)?
Yes No ______Have you ever been hospitalized or attended residential treatment for mental health reasons (please describe)? Yes No ______Have you ever thought about or attempted suicide (please explain)? Yes No ______Have you ever attended any type of counselling (please explain)? Yes No ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
Please check “Y” (Yes) or “N” (No) for each question in BOTH columns: Within last 6 Ever? months Y N Y N 1. Have you had a period of time when you were feeling up, hyper, or so full of energy or full of yourself that you got into trouble, or that other people thought you were not your usual self? (Do not consider times when you were intoxicated on drugs or alcohol?)
2. Have you ever been so irritable, grouchy, or annoyed for several days, that you had arguments, had verbal or physical fights, or shouted at people outside your family? Have you or others noticed that you have been more irritable or overreacted, compared to other people, even when you thought you were right to act this way?
3. Have you had one or more occasions when you felt intensely anxious, frightened, uncomfortable or uneasy, even when most people would not feel that way? Did these intense feelings get to be their worst within 10 minutes? (If the answer to both questions is “yes”, circle “yes”; otherwise circle “no”.
4. Do you feel intensely anxious or uneasy in situations where help might not be available or escape might be difficult? (i.e., being in a crowd; standing in a line; being alone away from home or alone at home; crossing a bridge; travelling in a bus, train, car or airplane)
5. Have you been bothered by thoughts, impulses, or images that you couldn’t get rid of that were unwanted, distasteful, inappropriate, intrusive, or distressing? (i.e., being afraid you would act on some impulse that would be really shocking; worrying a lot about being dirty, contaminated, or having germs; worrying a lot about contaminating others, or that you would harm someone even though you didn’t want to; having fear or superstitions that you would be responsible for things going wrong; being obsessed with sexual thoughts, images or impulses; hoarding or collecting lots of things; having religious obsessions)
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
Please check “Y” (Yes) or “N” (No) for each question in BOTH columns: Within last 6 Ever? months Y N Y N 6. Did you do something repeatedly without being able to resist doing it? (i.e., washing or cleaning obsessively; counting or checking things over and over; repeating, collecting, or arranging things)
7. Have you ever experienced, witnessed, or had to deal with an extremely traumatic event that included actual or threatened death or serious injury to you or someone else?
8. Have you re-experienced the awful event in a distressing way? (i.e., dreams; intense recollections; flashbacks; physical reactions)
9. Have you ever believed that people were spying on you, or that someone was plotting against you, or trying to hurt you?
10. Have you ever believed that someone or some force outside of yourself put thoughts in your mind that were not your own, or made you act in a way that was not your usual self? Or, have you ever felt that you were possessed?
11. Have you ever believed that you were being sent special messages through the T.V., radio, internet, or newspaper? Did you believe that someone you did not personally know was particularly interested in you?
12: Have you ever heard things other people couldn’t hear, such as voices? Or, have you ever had visions when you were awake or have you ever seen things other people couldn’t see?
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
Pick the one sentence that best describes your overall feelings about yourself. “In general, I am…” “As compared with most people, I think I have…”
Very happy with who I am Very good self-esteem Happy with who I am Good self-esteem Okay with who I am but have some Average self-esteem mixed feelings Poor self-esteem Unhappy with who I am Very poor self-esteem Very unhappy with who I am
PROGRAM PREPARATION
What do you hope to achieve by participating in your choice of program? ______
What has made losing weight and maintaining weight loss a challenge for you in the past? ______
Who will support you through your efforts in this process? Name How will they specifically help you?
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
List your personal strengths: ______
Current activities and/or hobbies that you enjoy: ______
Surgical Program Only: What is your specific plan for Toronto when you go for surgery? (i.e., how will you get there; who will travel with you; where will you stay, etc.) ______
Is there anything else you would like to share with us that you haven’t already shared? ______
Revised May 2019
Bariatric Regional Assessment & Treatment Centre Sudbury Outpatient Centre 865 Regent Street South Sudbury, Ontario P3E 3Y9
Phone: 705-671-5611 Fax: 705-671-5635
BRATC Patient Questionnaire
KNOWLEDGE OF BARIATRIC PROGRAMS
Have you researched Bariatric Surgery Yes No Medical (Optifast®) Program Yes No
If yes, where did you get the information? Check all that apply Internet Friend Former Patient Doctor Book Support Group Other ______
What did you research or learn? Check all that apply Surgical Program: Medical (Optifast®) Program Comparison of surgical procedures Optifast® formulation Risks and complications Risks and complications Diets Medical Supervision Supplements needed Supplements needed Techniques of eating Program commitment Other patients’ experiences Other patients’ experiences Success rates Success rates
______Patient Signature Date Completed
Revised May 2019
R E G E N T
S T
York Street York Street
P A R Hospital Parking Lot I S
Health Sciences S T North, Sudbury R outpatient R E E E centre G T H E N T
S T R E E T