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Pre-Op Assesment Forms

Snowcrystal

New Member
I thought I would post this form that my surgeon uses as it might help those still waiting.

Post bypassers and banders was your pre-op assessment form like this one?




Section 1: Personal details

Name:_______________________________ Sex: Ο M Ο F Date of birth:________
Address:________________________________________________________________

_______________________________________________________________________

E-mail address:__________________________________________________________

Height: ___________________ Weight: __________________ BMI: ______________

Home Phone: (______) ________ Work Phone: (_____) _______ Mobile: ___________

GP Details: Name _________________________ Phone:____________________

Address:________________________________________________________________

_______________________________________________________________________


Marital Status: Ο Single Ο Married Ο Divorced Ο Live with partner

Children: Ο No Ο Yes How many ____________

Occupation: _____________________________________________________________


It would be helpful if you could keep a one week diet history sheet detailing all foods eaten in the week before your consultation.

Which Weight Loss procedure are you interested in?

Ο Laparoscopic Gastric Band Ο Laparoscopic Roux-en-Y Gastric Bypass
Ο Laparoscopic Duodenal Switch Ο Laparoscopic Revision Bariatric Surgery
Ο Not sure

Have you had Weight Loss Surgery before? Ο Yes Ο No

Operation: __________________________________ Date:__________________

Hospital: ____________________________________ Surgeon: _______________
Section 2: Weight Loss History

How long have you been overweight? _____________________

Please provide details of any diets you have tried

Diet Date Duration Maximum weight loss
Weight Watchers
Jenny Craig
Nutri/System
Atkins Diet
Slimfast
Optifast
Herbalife
Liquid Diets
Other _____________


Please provide details of any medication you have tried

Medication Date Duration Maximum weight loss
Amphetamines
Phentermine (Fastin)
Phen-Fen
Xenical (Orlistat)
Dexfenfluramine (Reduxil)
Meridia (Sibutramine)
Other _______________


Please provide details of any other therapies you have tried

Therapy Date Duration Maximum weight loss
Exercise
Hypnosis
Behaviour Modification
Other _______________

Section 3: Medical History – Obesity Related


Cardiovascular Yes No Not sure Date diagnosed
Angina
Heart Attack
Heart Bypass Surgery
Angioplasty
Palpitations (abnormal heart beat)
Congestive heart failure
High Blood Pressure
High Cholesterol


Diabetes Yes No Not sure Date diagnosed
Onset – as a child
Onset – as an adult
Onset – due to pregnancy
Diet controlled
Oral medications
Insulin injections


Respiratory Yes No Not sure Date diagnosed
Asthma
Shortness of breath
Sleep Apnoea
Do you use a CPAP machine?
Snoring
Waking at Night
Daytime drowsiness






Joint Pain Yes No Not sure Date diagnosed
Pain or arthritis in your joints
Pain or sciatica in your back
Difficulty walking or exercising
Do you take prescribed medication?
Do you take over the counter medication?

Legs and Veins Yes No Not sure Date diagnosed
Leg or ankle swelling
Leg ulceration
Leg skin colour changes
Deep Vein Thrombosis
Pulmonary embolism
Do you require blood thinning medication?

Hernia Yes No Not sure Date of surgery
Incisional Hernia
Umbilical Hernia
Inguinal Hernia
Any hernia present at this time?

Reflux/heartburn Yes No Not sure Date diagnosed
Hiatus Hernia
Relux or Heartburn
Have you ever needed an endoscopy
Do you take prescribed medication?
Do you take over the counter medication?

Menstruation Yes No Not sure Date diagnosed
Any irregularities?
Infertility
Are you losing weight to become pregnant?



Section 4: Past Medical History


Please provide details of any medical conditions or illnesses not yet mentioned

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide details of any hospital admissions you have had in the past
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide details of any operations you have had in the past
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide details of any allergies that you have. What reaction do you have?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please provide details of any medications you currently take
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Do you smoke? Ο Yes Ο No Ο Ex-smoker
How many a day? ___________________
Do you drink alcohol? Ο Yes Ο No Ο Occasional
How much a week? _________________


Have you ever received treatment for depression? Ο Yes Ο No
Have you ever been hospitalized for mental illness? Ο Yes Ο No


Family History – please tick if any of your family members have the following:

Yes Relationship
Obesity Ο ___________________
High Blood Pressure Ο ___________________
Heart Disease Ο ___________________
Stroke Ο ___________________
Lung Disease Ο ___________________
High Cholesterol Ο ___________________
Breast Cancer Ο ___________________
Colon Cancer Ο ___________________
Other Cancers Ο ___________________
Kidney Disease Ο ___________________
Diabetes Ο ___________________
Blood disorders Ο ___________________
Tendency to bleed Ο ___________________







Section 5: Please tick if you have had/are having any of these symptoms:


General
__ fatigue
__ tiredness
__ night sweats
Head and Neck
__ blurred vision
__ loss of vision
__ loss of hearing
__ dizziness
__ vertigo
__ sinus problems
__ loss of smell
__ difficulty swallowing
__ lump in neck
Cardiovascular
__ chest pain
__ pounding heart
__ pain in arms or neck
__ heart attack
__ palpitations
__ heart murmur
__ stroke
__ high blood pressure
__ pain in legs
__ cold feet
__ loss of pulses
Respiratory
__ shortness of breath
__ asthma
__ wheezing
__ bloody sputum
__ emphysema
___ pneumonia
___ bronchitis
Gastrointestinal
___ jaundice
___ hepatitis
___ cirrhosis
___ vomiting
___ nausea
___ heartburn
___ abdominal pain
___ diarrhoea
___ constipation
___ blood in stools
___ haemorrhoids
___ irritable bowel
___ colitis
Genitourinary
___ blood in urine
___ pain with urine
___ bladder infection
___ kidney stones
___ kidney infection
___ discharge from penis
___ loss of erection
___ vaginal discharge
___ abnormal vaginal bleeding
___ irregular periods
Musculoskeletal
___ muscular aches
___ swelling of joints
___ arthritis
___ sciatica
___ pain in knees
___ pain in ankles
___ pain in feet
___ pain in hips
___ pain in lower back
___ slipped disc
___ numbness in feet/legs
Endocrine
___ diabetes
___ hyperthyroid
___ low thyroid
___ goitre
___ swollen glands
___ previous steroid use
Skin/Breast
___ skin cancer
___ abnormal moles
___ breast lump
Neurological
___ convulsion or fit
___ fainting
___ falling
___ muscle weakness
___ loss of consciousness
Psychological
___ depression
___ suicidal thoughts
___ anxiety
___ suicide attempts
___ eating disorder
___ required counselling
___ mental illness


I know it was a long one........thanks for looking though!

~hugs~
 
Last edited:

debbiejane

New Member
mine was similar x
 

yorkshiregirl78

New Member
Mine was fairly much the same but i was never asked about diets I have had before or the pills I have tried before!!
Suppose they are all diffrent in their own little ways!
 

julia in bath

New Member
very useful, thanks for posting
 

Snowcrystal

New Member
Yes it is lengthy...I am still not sure that this will be the one I will have to fill out as this is the form I would have to fill out if I went private with this surgeon...I am assuming that he would run his NHS clinic in the same way he runs his private clinic.

~hugs and patience~
 

farzu

New Member
Thanks a lot snowcrystal, it will definately help those who are still waiting. atleast we now know what kind of forms we will have to fill.
 

Snowcrystal

New Member
Thanks a lot snowcrystal, it will definately help those who are still waiting. atleast we now know what kind of forms we will have to fill.

You're welcome Farzu

Well it gives an idea of what it might be like as they probably differ from one PCT to another.

I thought well at least we know some of the questions we are likely to be asked.

~hugs~
 
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