123456 1. Contact informationPersonal Full name All names as stated in passport Phone Please do not forget to add a regional/area code. Email Street City ZIP code Country Gender Male Female Birth date dd.mm.yy Preffereble units Metric (cm, kg) Imperial (in, lbs) Current weight (kg) Highest lifetime weight (kg) Height (cm) Weight (st &lbs) Highest lifetime weight (st & lbs) Height (ft & in) Emergency contact Name Phone Please do not forget to add a regional/area code. 2. Choice of surgery Which surgery would You prefer? Laparoscopic Gastric Bypass Laparoscopic Sleeve Gastrectomy Laparoscopic Mini-Gastric Bypass Sleeve-bypass (SASI) Revision surgery Uncertain Have You tried any weight loss methods before? No Yes What is your primary reason for wanting weight loss surgery? How do you assess your knowledge on nutrition? Modest Mediocre Excellent Which of the following are problem eating behaviors for you? Large Portions No Yes Bad food choices No Yes Emotional Eating (stress eating) No Yes Bing eating No Yes Snacking No Yes Sweets No Yes Skipping Meals No Yes Are you vegan? No Yes Please tick the box if you often have: constipation diarrhea Are there any foods that you can't eat for whatever reason? yes no (allergy, lactose intolerance, religion, veganism, etc.) If yes, please specify 3. Medical history Have you had prior weight loss surgery? No Yes Please describe Have you had any operations before? No Yes *OperationDate Medical problems Do You have diabetes? No Yes Do you have sleep apnea? No Yes Have you been prescribed CPAP? No Yes Do you have high blood pressure? No Yes Do you have high cholesterol? No Yes Do you have heart disease? No Yes Please describe Do you have heartburn or GERD that needs medication? No Yes Do you have joint pains that limit your activity level? No Yes Which joints (e.g. low back, knees)? Have you ever had a blood clot or pulmonary embolism? No Yes List all other current and past medical problems: 4. Medications Do you take any medicines (incl. over the counter and supplements)? Yes No Have You had allergic reactions toward any medications? No Yes Which medications are You allergic to? List all medications you are taking, including dosage and frequency. Include all over the counter medications and supplements you take.*MedicationDoseFrequency Smoking and drinkingDo You smoke? How often? I do not smoke < 1 cigarette a day 1-3 cigarette a day 4-6 cigarette a day > 6 cigarette a day How often do you consume alcohol? I do not consume alcohol A couple of times a month Once a week 2-3 times a week > 4 times a week 5. Review of systemsRespiratory Shortness of breath at rest? Never Past Now Frequent pneumonia or bronchitis? No Yes Have you been diagnosed or treated for asthma? No Yes Cardiovascular Chest pain or angina pectoris? Never Past Now Have you ever had palpitations/arrhythmia? No Yes Have you had a heart attack? No Yes Do you have shortness of breath after climbing one flight of stairs? No Yes Gastrointestinal Have you ever had ulcers in oesophagus, stomach or duodenum? No Yes Have you ever had liver disease (e.g. hepatitis, cirrhosis, etc)? No Yes Have you been told that you have gallstones? No Yes Do you get recurring abdominal pain? No Yes Family planning Have you ever had pregnancies or abortions? No Yes Are you planning pregnancies in the future? No Yes Please tick the box if you use: Oral contraceptives containing oestrogen or progesterone Transdermal contraceptive patches containing oestrogen or progesterone Intrauterine device (IUD) Contraceptive implant Combined injectable contraceptives I don't use contraceptives containing estrogen or progesterone Musculoskeletal Do you have arthritis? No Yes Do your ankles ever swell? No Yes Please choose if have joint pain in: Back Hips Knees Ankles Feet Please tick the box if you use mobility aids like: Walking sticks Rollator/walking frame Wheelchair Mobility scooter Psychological/emotional Have you ever seen a psychiatrist or psychologist? No Yes Have you ever been hospitalized for psychiatric reasons? No Yes Are you taking any medications? No Yes Hematological Have you had anemia? No Yes Have you had excessive bleeding or abnormal bruising? No Yes Have you ever received a blood transfusion? No Yes What was the reason? Does your religion prohibit you from having a blood transfusion should you need one? No Yes 6. Additional Information Please provide Your additional questions, if you have any: I have been honest and thorough with filling the form. I understand that incorrent and not complete fulfilment of the form can be the reason for declining the operation. I give my consent to Bariatric Services AS for the processing of the personal data in the above form in accordance with the privacy policy given herein in order to assess whether the bariatric surgery is indicated to me. PhoneThis field is for validation purposes and should be left unchanged. 123456 1. Contact informationPersonal Full name All names as stated in passport Phone Please do not forget to add a regional/area code. Email Street City ZIP code Country Gender Male Female Birth date dd.mm.yy Preffereble units Metric (cm, kg) Imperial (in, lbs) Current weight (kg) Highest lifetime weight (kg) Height (cm) Weight (st &lbs) Highest lifetime weight (st & lbs) Height (ft & in) Emergency contact Name Phone Please do not forget to add a regional/area code. 2. Choice of surgery Which surgery would You prefer? Laparoscopic Gastric Bypass Laparoscopic Sleeve Gastrectomy Laparoscopic Mini-Gastric Bypass Sleeve-bypass (SASI) Revision surgery Uncertain Have You tried any weight loss methods before? No Yes What is your primary reason for wanting weight loss surgery? How do you assess your knowledge on nutrition? Modest Mediocre Excellent Which of the following are problem eating behaviors for you? Large Portions No Yes Bad food choices No Yes Emotional Eating (stress eating) No Yes Bing eating No Yes Snacking No Yes Sweets No Yes Skipping Meals No Yes Are you vegan? No Yes Please tick the box if you often have: constipation diarrhea Are there any foods that you can't eat for whatever reason? yes no (allergy, lactose intolerance, religion, veganism, etc.) If yes, please specify 3. Medical history Have you had prior weight loss surgery? No Yes Please describe Have you had any operations before? No Yes *OperationDate Medical problems Do You have diabetes? No Yes Do you have sleep apnea? No Yes Have you been prescribed CPAP? No Yes Do you have high blood pressure? No Yes Do you have high cholesterol? No Yes Do you have heart disease? No Yes Please describe Do you have heartburn or GERD that needs medication? No Yes Do you have joint pains that limit your activity level? No Yes Which joints (e.g. low back, knees)? Have you ever had a blood clot or pulmonary embolism? No Yes List all other current and past medical problems: 4. Medications Do you take any medicines (incl. over the counter and supplements)? Yes No Have You had allergic reactions toward any medications? No Yes Which medications are You allergic to? List all medications you are taking, including dosage and frequency. Include all over the counter medications and supplements you take.*MedicationDoseFrequency Smoking and drinkingDo You smoke? How often? I do not smoke < 1 cigarette a day 1-3 cigarette a day 4-6 cigarette a day > 6 cigarette a day How often do you consume alcohol? I do not consume alcohol A couple of times a month Once a week 2-3 times a week > 4 times a week 5. Review of systemsRespiratory Shortness of breath at rest? Never Past Now Frequent pneumonia or bronchitis? No Yes Have you been diagnosed or treated for asthma? No Yes Cardiovascular Chest pain or angina pectoris? Never Past Now Have you ever had palpitations/arrhythmia? No Yes Have you had a heart attack? No Yes Do you have shortness of breath after climbing one flight of stairs? No Yes Gastrointestinal Have you ever had ulcers in oesophagus, stomach or duodenum? No Yes Have you ever had liver disease (e.g. hepatitis, cirrhosis, etc)? No Yes Have you been told that you have gallstones? No Yes Do you get recurring abdominal pain? No Yes Family planning Have you ever had pregnancies or abortions? No Yes Are you planning pregnancies in the future? No Yes Please tick the box if you use: Oral contraceptives containing oestrogen or progesterone Transdermal contraceptive patches containing oestrogen or progesterone Intrauterine device (IUD) Contraceptive implant Combined injectable contraceptives I don't use contraceptives containing estrogen or progesterone Musculoskeletal Do you have arthritis? No Yes Do your ankles ever swell? No Yes Please choose if have joint pain in: Back Hips Knees Ankles Feet Please tick the box if you use mobility aids like: Walking sticks Rollator/walking frame Wheelchair Mobility scooter Psychological/emotional Have you ever seen a psychiatrist or psychologist? No Yes Have you ever been hospitalized for psychiatric reasons? No Yes Are you taking any medications? No Yes Hematological Have you had anemia? No Yes Have you had excessive bleeding or abnormal bruising? No Yes Have you ever received a blood transfusion? No Yes What was the reason? Does your religion prohibit you from having a blood transfusion should you need one? No Yes 6. Additional Information Please provide Your additional questions, if you have any: I have been honest and thorough with filling the form. I understand that incorrent and not complete fulfilment of the form can be the reason for declining the operation. I give my consent to Bariatric Services AS for the processing of the personal data in the above form in accordance with the privacy policy given herein in order to assess whether the bariatric surgery is indicated to me. PhoneThis field is for validation purposes and should be left unchanged.
