Bariatric Assessment Questionnaire version October 2017
1 of 13 pages Bariatric Assessment Questionnaire version October 2017
Dear Patient,
We would like to offer an opportunity to check your suitability for bariatric (weight loss) surgery.
Please report to outpatients 2 reception on your arrival & ensure you:
Complete and bring the attached questionnaire Bring a copy of your recent prescription medications
Please allow a full day for the assessment process which involves:
Assessment with bariatric Dietitian or Nurse (1 hour) Any extra appointments agreed for example: psychology assessment physiotherapy group class (PACE) pre-op dietetic appointments physiotherapy assessment smoking cessation tier 3 or equivalent weight program Other: ______
Assessment with bariatric Surgeon (1/2 hour) Any extra tests agreed by surgeon for example: OGD sleep studies exercise tolerance test physician chemical pathologist Other: ______
Blood test – in main outpatients or Picton Suite on the 1st floor.
ECG test - follow signs for x-ray 2, then the sign for cardiology and lung function test.
Bariatric assessment information group (1 and 1/2 hours) in seminar room of outpatients 2. It covers the types of surgery on offer and how surgery will affect your eating habits long-term. Time will be allocated for questions at the end. Agreed date and time if different from assessment date: ______
Achieve 5% weight loss target in the coming 3 to 6 months. Assessment date: Weight: BMI: kg/m2 5% weight loss target agreed: Weight: BMI: kg/m2
Once the above is complete a decision regarding your suitability for surgery can be made. If you need more information you can contact us on the details below.
We look forward to meeting you,
Yours sincerely,
The Homerton Bariatric Surgery Department 020 8510 7496 or [email protected]
2 of 13 pages Bariatric Assessment Questionnaire version October 2017
Tick & choose Suggested goals to help lose the required 5% of weight & help prepare forPatient possible History bariatric Questionnaire surgery Increase knowledge about bariatric surgery to make informed choice NHS Choices Weight loss surgery https://www.nhs.uk/conditions/weight- loss-surgery/ Weight loss surgery information website http://www.wlsinfo.org.uk/ Read Homerton booklet your guide to weight loss services Attend Homerton monthly Bariatric Support Group Join Bariatric Facebook group or Online Forum Become familiar with bariatric cookbooks for ideas post-op Increase awareness of dietary changes / eating habits & complications of non-compliance like dumping syndrome & reasons it is possible to re-gain weight after surgery Eating behaviors Meal planning Regular of eating Slow/mindful eating Regulation of unhealthy snacking Frequency/severity of binge eating Night eating/secret eating Use of takeaways/fast food Boredom / emotional/ comfort eating Dietary intake Portion control Self-monitoring of diet and activity via diary or phone app Reduction in intake of sugar/refined carbohydrate Intake of sugar-sweetened/high calorie fizzy drinks Reduction in intake of high calorie/high fat foods Protein at every meal Increased intake of fruit and vegetables Environmental Typical day example of life after surgery e.g. when will I take medications, supplements, separating eating from drinking by 30 minutes, meal & drink planning ahead Food shopping habits Eating environment e.g. not eating in front of a screen Dental check-up Improved sleep hygiene Smoking cessation/reduction Planned physical activity/exercise Vitamin & mineral deficiencies Commenced supplementation of 1 daily A to Z complete vitamin and mineral supplement from now until day of possible surgery If any deficiencies identified in bariatric blood test to make appointment with GP and commence supplements. Re-test with GP 3 months later to ensure levels normalized. Achieve 5% weight loss target in the coming 3 to 6 months. Height: Any recent tier 3 or equivalent: Weight: BMI: kg/m2 Date of Referral: Weight: BMI: kg/m2 Assessment date: Weight: BMI: kg/m2 3 of 13 pages 5% weight loss target: Weight: BMI: kg/m2 Bariatric Assessment Questionnaire version October 2017
The information requested in this questionnaire is very important. To give you the best care we must have complete answers. Please be thorough. Blue or black ink only please.
Name:______Age: ______Gender: ______
Occupation (if retired, what did you do?): ______
Current body weight: ______Target weight you wish to achieve:______
Height: ______
Body frame (circle one): Small Medium Large
Epworth Sleep Questionnaire
How likely are you to doze off or fall asleep in the situations described in the box below, compared to just feeling tired?
Even if you haven’t done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Chance of Dozing Sitting Reading
Watching TV
Sitting inactive in a public place (e.g. a theatre of a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone
Sitting quietly after lunch without alcohol
Driving in a car, while stopped a few minutes in the traffic
TOTAL Patient Health Questionnaire - 9
4 of 13 pages Bariatric Assessment Questionnaire version October 2017
Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several More than Nearly Days half the days every day
1 Little interest or pleasure in doing things 0 1 2 3 2 Feeling down, depressed, or hopeless 0 1 2 3
3 Trouble falling or staying asleep, or sleeping 0 1 2 3 much 4 Feeling tired or having little energy 0 1 2 3 5 Poor appetite or overeating 0 1 2 3 6 Feeling bad about yourself – or that you are a failure or have let yourself or your family down 0 1 2 3 7 Trouble concentrating on things, 0 1 2 3 such as reading the newspaper or watching television 8 Moving or speaking so slowly that other people could have noticed? 0 1 2 3 Or the opposite: being so fidgety or restless that you have been moving around a lot more than usual 9 Thoughts that you would be better off dead or of hurting yourself in someway 0 1 2 3
Column Totals ___ + ___ + ___
Add Totals Together = ______
If you checked off any problems, how difficult have those problems made it for you to
Do you work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very Difficult
Extremely difficult
Generalized Anxiety Disorder - 7
5 of 13 pages Bariatric Assessment Questionnaire version October 2017
Over the last 2 weeks, how often have you been bothered by any of the following problems
Not at all Several More than Nearly Days half the days everyday
1 Feeling nervous, anxious or on edge 0 1 2 3
2 Not being able to stop or control worrying 0 1 2 3
3 Worrying too much about different things 0 1 2 3
Trouble relaxing 0 1 2 3
4 Being so restless that it is hard to sit still 0 1 2 3
5 Feeling afraid as if something awful might 0 1 2 3 happen
Column Totals ___ + ___ + ___
Add Totals Together = ______
If you checked off any problems, how difficult have those problems made it for you to
Do you work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very Difficult
Extremely difficult
Weight history Please estimate as closely as possible for all that applies.
6 of 13 pages Bariatric Assessment Questionnaire version October 2017
Life event Age Weight Birth weight Start of secondary school End of secondary school Marriage Lowest weight in past 5 years Highest weight in the past 5 years
Briefly describe why you are interested in having weight loss surgery: ______
What background information have you gathered about weight loss surgery and do you have any concerns? ______
Dieting history
Approximate age when you first seriously dieted: ______
Smoking or Alcohol Do you smoke? Yes No Number of cigarettes______Are you willing to stop? Yes No Do you drink alcohol? Yes No Frequency______
Allergies: Allergic to any medications? Yes No If yes: list medication and reaction:______
Allergic to: Surgical tape? Yes No Latex? Yes No Iodine? Yes No
Other allergies______
Medications: Please list below all the medications you currently use or alternatively bring a copy of your recent prescription medications:
7 of 13 pages Bariatric Assessment Questionnaire version October 2017
Medication Dose and frequency
Please sign and date if you are happy to consent for our bariatric pharmacist to contact your GP regarding your up-to-date medications
Date: ______Sign: ______
List the diets, medications and diet programmes you have tried:
Year + Length of attendance + weight loss achieved: NHS Weight Management Programme Yes No ______Dietitian Yes No ______Exercise on Referral Yes No ______Xenical (Orlistat) Yes No ______Weight Watchers Yes No ______If yes - please circle if you attended; group or online or recipes or ready meals / snacks
Slimming World Yes No ______If yes; please circle if you attended; group or online or recipes or ready meals / snacks Cambridge Diet Yes No ______Lighter Life Yes No ______Slimfast Yes No ______Atkins diet Yes No ______Rosemary Conley diet Yes No ______List any other diets and/or weight loss methods you have tried: ______List eating triggers and reasons for weight regain:
8 of 13 pages Bariatric Assessment Questionnaire version October 2017
______For female Poly-cystic ovary syndrome? Yes No patients only: Irregular / infrequent periods? Yes No Age at first period______Date of last period______Previous Hysterectomy? Yes No Number of pregnancies______Number of live births______Miscarriages/abortions______Obstetric complications______
Pregnancy 1 Year_____ weight at start______at delivery______
Pregnancy 2 Year_____ weight at start______at delivery______
Pregnancy 3 Year_____ weight at start______at delivery______
Pregnancy 4 Year_____ weight at start______at delivery______
Do you presently use: Oral contraceptive pill Yes No List type______Other contraceptive method______
Weight related illnesses Have you had, or do you have any of the following illnesses or symptoms?
1. Diabetes Yes No If yes: Type 1 Type 2 Year diagnosed ______
Gestational diabetes: Yes No Neuropathy: Yes No Controlled with: Diet Medications______Insulin______Last fasting blood sugar:______
2. High blood pressure Yes No If yes: Year diagnosed______List medications______
9 of 13 pages Bariatric Assessment Questionnaire version October 2017
3. Heart disease Yes No If yes: Year diagnosed______Do you have or have had: Angina Atherosclerosis MI (myocardial infarction, ‘heart attack’) CABG (coronary artery bypass graft Abnormal ECG (echo cardiogram) Stress test to rule out cardiac problems Palpitations
4. High cholesterol Yes No High Triglycerides Yes No If yes: Year diagnosed______List medications______
5. Asthma Yes No If yes: Year diagnosed______A&E visits in the last 2 years______Admitted to hospital in the last 2 years______Steroids last 2 years______
6. Shortness of breathe Yes No If yes: Requires wheelchair / house-bound Can walk ______metres without resting Stairs ______flights without resting
7. Gallbladder disease? Yes No If yes: How was it diagnosed? Ultrasound Physical exam
8. Trouble sleeping Yes No Morning headaches Daytime drowsiness Restless sleep Snoring Awakenings at night Observed apnoea
9. Sleep apnoea Yes No If yes: Year diagnosed______Last sleep study: ______CPAP / BIPAP used Yes No
10. Heartburn/oesophagitis/hiatus hernia Yes No If yes: Year diagnosed______Endoscopy Yes No Medications______
10 of 13 pages Bariatric Assessment Questionnaire version October 2017
Frequency of use______
11. Burping up acid or sour fluid Yes No
12. Choking or coughing at night? Yes No
13. Leakage of urine with laughing/coughing/sneezing? Yes No If yes: Wear pads frequently? Yes No
14. Lower back strain/pain/sciatica Yes No If yes: Seen by chiropractor? Yes No Orthopaedic surgeon? Yes No GP? Yes No Medications taken______Arthritis? Yes No
15. Pain in hips/knees/ankles/feet? Yes No If yes: Seen by chiropractor? Yes No Orthopaedic surgeon? Yes No GP? Yes No Medications taken______
16. Weight related injuries and trauma:______
17. Venous stasis disease? Yes No If yes: Do you have oedema? Yes No Scaly and thick skin? Yes No Leg ulcers? Yes No
18. Gout? Yes No If yes: Gouty arthritis? Yes No Medications taken______
19. Bra size (females only):______Skin depressions from bra straps? Yes No Do you have shoulder pain? Yes No
20. Depression Anti-depressant medication Yes No Hospitalisation for depression Yes No
21. Do you have any history of Deep vein thrombosis? Yes No 22. Liver disease? Yes No
11 of 13 pages Bariatric Assessment Questionnaire version October 2017
Past medical history Please identify which of the following childhood illnesses you have experienced:
Measles Mumps Chickenpox Obesity
Rheumatic fever Heart murmur Asthma Tonsillectomy
Serious illness
Have you had: Hepatitis Blood transfusion AIDS/HIV exposure Colitis Kidney disease Bleeding abnormality Thyroid problems
Please list below all serious illnesses and hospitalisations you have experienced in adulthood:
Major illness Date Treatment ______
Major surgery Date Treatment ______
Please circle all symptoms you currently experience, or have experienced in the past. 1. Head, eye, ear, nose and throat: stuffy nose -runny nose -hay fever -sinus trouble – earache –headache -blurry vision -double vision -halos around lights -loss of night vision -buzzing in ears -ringing in ears -discharge from ear - loss of hearing –dizziness – vertigo -loss of balance -sore throat -lump in throat -trouble swallowing -pain with swallowing –hoarseness 2. Respiratory: cough –wheezing –shortness of breath at night –use of two pillows – blood in sputum –out of breath with exertion –wake up at night short of breath –wake up at night coughing or choking –asthma –emphysema –bronchitis 3. Cardiovascular: palpitations –pounding heart –skipping heartbeat –pains in chest – pains in neck –squeezing of chest –heart attack –heart murmur –abnormal electrocardiogram –irregular heartbeat –high blood pressure –pain in legs –cold feet – blue toes –blue finger –loss of pulses
12 of 13 pages Bariatric Assessment Questionnaire version October 2017
4. Gastrointestinal: heartburn –nausea –vomiting –belching fluid in throat –burning in throat –food sticking in chest –pains in stomach –burning in stomach –acid stomach – diarrhoea –constipation –pain with bowel movement –blood in stools –haemorrhoids – fissures –cramps –gassiness –irritable colon –colitis 5. Genitourinary: pain with urination –trouble starting urination –trouble stopping urine –small urine stream –blood in urine –kidney stones –bladder stones –kidney failure – nephritis –urinary tract infections –frequent urination –getting up in the night to urinate – leakage of urine with cough or sneeze Men: discharge from penis –loss of erection –painful erection Women: vaginal discharge –vaginal bleeding –pain with intercourse –irregular periods
6. Endocrine (glandular): low thyroid –raised thyroid –goitre –Grave’s Disease – thyroid nodules –x-ray to thyroid –diabetes –adrenal gland tumour –frequent flushing – frequent heavy sweating
7. Musculoskeletal: pain in joints –swelling of joints –redness of skin over joints –warm joints –fluid in joints –arthritis –broken bones –sprains –low back pain –hip pain –knee pain –ankle pain –foot pain –flat feet –slipped disc –herniated disc –sciatica
8. Neurological: dizziness –vertigo –falling to the side –falling at night –numbness – tingling –pins and needles feelings –weakness of any muscles –twitching of muscles – weakness of grip –shakiness –tremors –fainting –convulsions –fits –loss of consciousness
9. Psychological: nervousness –anxiety –depression –thoughts of suicide –suicide attempts –hospitalisation for emotional problems –psychiatric treatment –psychological counselling
Family history
Family Living? Age If deceased, Illness/cause member age of death Mother
Father
Maternal grandmother Maternal grandfather Paternal grandmother Paternal grandfather
13 of 13 pages Bariatric Assessment Questionnaire version October 2017
Brother/Sisters
Brother/Sisters
Brother/Sisters
Brother/Sisters
Please indicate if there is a family history of:
Obesity Lung disease, asthma or emphysema Diabetes Kidney disease High blood pressure Bleeding tendency or blood disorder Heart disease Breast cancer Colon cancer High cholesterol
Please complete and bring with you to your assessment appointment with bariatric dietitian or bariatric nurse.
Thank you.
14 of 13 pages