Highland Hospital / Bariatric Center / Surgical Options / Healthy Lifestyle & Meal Planning / Questionnaire Bariatric Surgery Questionnaire This 5-part questionnaire will help us learn more about you and help us establish your best path to weight loss. The form must be completed prior to scheduling your first appointment. A printable version of this form can be found here. For questions, please call 585-341-0366. Contact Information First Name* Last Name* Email* Phone* ( ) - Second three digits Last four digits Date of Birth Have you completed a bariatric seminar? YesNo, not yet Date of Seminar Calendar STOP! Before completing this form please attend a Bariatric Seminar. The first step in your weight loss journey will be to complete or schedule to attend a bariatric seminar. This comprehensive seminar will provide you with all the information you'll need in the weeks and months ahead. Sign up for a free Seminar today! Part 1: Medical History Please check condition that applies to you: Problems with AnesthesiaAcid RefluxAnginaAnxietyAsthmaBipolar DisorderBleedingBlood ClotBlood TransfusionCardiomyopathyCarpal TunnelCirrhosisClotting DisorderCongestive Heart FailureCOPDDepressionDiabetes Type 1Diabetes Type 2Difficulty SwallowingDizzy/Loss of Balance FatigueFibromyalgiaGallbladder DisorderGI UlcerGoutHeadachesHearing LossHeart AttackHigh Blood PressureHigh CholesterolHyperthyroidismHypothyroidismInsomniaIrritable Bowel SyndromeLeak Urine when Cough/SneezeLiver DiseaseLow Blood SugarLupusMalignant HyperthermiaMetabolic Disorder Morbid ObesityNumbness/TinglingOsteoarthritisPeripheral Vascular DiseasePolycystic Ovarian SyndromePseudotumor CerebriRash/Skin ProblemRheumatoid ArthritisSclerodermaSeizuresShortness of Breath/ on ExertionSleep ApneaSnoringStrokeSupraventricular TachycardiaSwelling in LegsVaricose VeinsVision ProblemsOther Please list other Have you ever had surgery? YesNo Select any surgery that applies to you: AdenoidectomyAppendectomyBariatric SurgeryBiliopancreatic DiversionBrain SurgeryBreast SurgeryCardio DefibrillatorColon/Large Intestine SurgeryCoronary AngioplastyC-Section Eye SurgeryFracture SurgeryGallbladder RemovalGastric Stimulator ImplantHeart BypassHeart StentsHeart Valve ReplacementHernia RepairHysterectomy Intestinal BypassJoint ReplacementPacemaker InsertionPlastic SurgerySmall Intestine SurgerySpine SurgeryTonsillectomyTubes TiedVertical Banded GastroplastyOther Please list other What type of Bariatric Surgery did you have? Sleeve GastrectomyDuodenal SwitchGastric BypassLap BandOther Indicate any known family history: Anesthesia Allergy No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Arthritis No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Asthma No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Cancer No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather COPD No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Depression No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Diabetes Type 1 No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Diabetes Type 2 No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Early Death No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Heart Disease No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather High Blood Pressure No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather High Cholesterol No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Kidney Disease No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Mental Illness No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Morbid Obesity No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Obesity No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Stroke No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Polyps on Colon No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Lung Cancer No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Other Condition Who has this condition No Family HistoryMotherFatherBrotherSisterSonDaughterMaternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather Are you disabled? YesNo How many years disabled Reason Disabled (check all that apply) Motor Vehicle AccidentWork Related InjuryIllnessOther Please list other reason Do you currently use an assistive device? YesNo Years in wheelchair/scooter Can you independently perform acts of daily living? (bathing, toileting, getting dressed, etc.) YesNo Do you perform any additional exercise? (Check all that apply) Walking/TreadmillChair exerciseSwimmingStationary Cycle/BikingOther Please list other How many times per week do you exercise? How long, in minutes, do you exercise each week? Functional Limits (check all that apply) No Impairment (can walk 200 ft without assistance)Require wheelchairBedriddenCane/CrutchCan only perform acts of daily livingRequires assistance with acts of daily livingDependent for acts of daily livingOther Please list other Part 2: Social History Do you drink alcohol? YesNo Please indicate the amount you drink each week: Wine (glasses per week) Beer (cans per week) Liquor (shots per week) Comments on alcohol use Do you currently use illicit/street drugs? (including medical marijuana) YesNo How many times/week? Marijuana Cocaine Methamphetamines Inhalants IV Date last used: Calendar Comments on drug use Do you use tobacco products? YesIn the pastNo Are you a smokeless tobacco user? VapeChewSnuffNone Comments on your history with tobacco Quit Date Calendar Sexually Active? YesNoNot Currently Birth Control | Protection AbstinenceCondomImplantInjectionIUDPillPatchPost-menopausalSurgicalNoneOther Other Part 3: Medications, Vitamins, & Allergies Do you take any medications or vitamins? YesNo Please list below all Medications and Vitamins you are currently taking. Ex. Lipitor, 10mg, one tablet daily at bedtime Name Dose Frequency Please list any allergies and reactions you may have Allergy Reaction Part 4: Sleep Assessment Answer the following questions based on your current sleep situation. How likely are you to doze off in these situations? Situation Chance of Dozing Sitting and reading Please select Never Slight Moderate High Watching TV Please select Never Slight Moderate High Sitting, inactive in a public place (ex. in a movie theater or a meeting) Please select Never Slight Moderate High As a passenger in a car for an hour or more Please select Never Slight Moderate High Lying down to rest in the afternoon Please select Never Slight Moderate High Sitting and talking Please select Never Slight Moderate High Sitting quietly after lunch (without alcohol consumption) Please select Never Slight Moderate High While driving a car, while stopped for a few minutes in traffic Please select Never Slight Moderate High How frequently do you snore or have you been told you snore loud enough to disturb other’s sleep? NeverRarely- less than once a weekOccasionally- 1-3 times a weekFrequently- More than 3 times a weekUnsure How often have you been told you pause or stop breathing while sleeping? NeverRarely- less than once a weekOccasionally- 1-3 times a weekFrequently- More than 3 times a weekUnsure Do you sleep during the day? YesNo Do you sleep excessively? YesNo Part 5: Weight Loss History Have you been morbidly obese for more than 5 years? YesNo Have you been obese since childhood? YesNo Have you been obese since pregnancy? YesNo Tell us about your previous weight loss attempts: Have you taken weight loss medications? YesNo AccutrimAmphetaminesAnorexBelviqByettaContraveDexatrimDidrexFastinFen-Phen Ionamine/AdipexMazanorMeridiaObalanPhendietPhentrolQsymiaPhenterminePleginePondimin ProzacReduxSanorexSaxendaTenulateTepanoleWelchlessWellbutrinXenical For Fen-Phen, what year and for how long did you use it? Please list other Weight Loss Medications What diet programs have you tried? Only document your weight loss attempts in the past 5 years Diet Program Number of Months Weight lost Physician Supervised? Year Atkins Jenny Craig LA Weight Loss Nutri-System Weight Watchers South Beach Registered Dietitian Optifast/ Medifast Calorie Controlled Please list any other diets you have tried in the last 5 years You have reached the end of the questionnaire, please click submit to take the next steps in your journey. Our Privacy Policy * Required