Bariatric Surgery



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|Community Specialist Weight Management Service Tier 3 |

|History Sheet |

Name: NHS Number:

Telephone Number: Consultant:

Weight Management Programme: Weight and Wellbeing Programme Yes No

If No other: …………………………………………… Date completed service: .…………………

| |

|Date………………....…….……………… |

| |

|Height ……….…………..……………… |

| |

|Weight ….……………kg ….…..…….St Ideal Body Weight 25x H2...……….Kg |

| |

|BMI ………………….……………kg/m2 |

| |

|Waist size…………………..cm………………ins Target Weightloss…………………….. |

Co-morbidity (medical problems)

|Are you diabetic? |Yes |No |

|If Yes, how long have you been diabetic |.........................Years |

|If Yes, please tick how this is managed | |

| |Insulin How much?............................................. |

| | |

| |Tablets Which ones?........................................... |

| |Diet alone |

|Do you have high blood pressure? |Yes |No |

|If Yes, please state what medication you are on: |

|............................................................................................................................................................. |

| |

|............................................................................................................................................................. |

Co-morbidity (medical problems) continued

|Have you had a heart attack? |Yes |No |

| | | |

|If Yes, please state when? |

|Do you have any other heart problems? |Yes |No |

|If Yes, please state: |

|............................................................................................................................................................. |

|Do you have high cholesterol? |Yes |No |

|If Yes, please state what medication you are on: |

|....................................................................................................................................................... |

| |

|....................................................................................................................................................... |

|Do you have Arthritis/Joint pains? |Yes |No |

|If Yes, please tick the following: Hips |Left |Right |

| Knees |Left |Right |

| Spine |Yes |No |

| | | |

| |

|Do you suffer with asthma? |Yes |No |

|If Yes, please state what medication you are on: |

|............................................................................................................................................................ |

|Do you have regular indigestion? |Yes |No |

|If Yes, what medication you take |

|............................................................................................................................................................. |

|Do you have sleep apnoea? |Yes |No |

Health and Lifestyle

|Do you smoke? |Yes |No |

|If Yes, how many cigarettes do you smoke? | |

| |cigarettes a day |

|Do you drink alcohol? |Yes |No |

|If Yes, how many units you drink? | |

| |units a week |

Weight Loss

|Have you attended any weight loss programs in the |Yes |No |

|community? | | |

|Please describe your previous weight loss/es and also | |

|state your maximum weight loss. |................................................................................................ |

| |................................................................................................ |

| |................................................................................................ |

| |............................................................................................... |

| |Maximum Weight loss............................................................ |

|Have you attended Slimming Clubs? |Yes |No |

|Have you attended Gym or Exercise classes? |Yes |No |

|Have you taken Orilstat (Xenical)? |Yes |No |

|Have you taken Sibutramine (Reductil)? |Yes |No |

|Have you been to a Dietician? |Yes |No |

|Have you been seen by a Hospital Dietician? |Yes |No |

|Have you attended a hospital weight reduction clinic? |Yes |No |

|Do you want to be considered for Bariatric Surgery? |Yes |No |Undecided[pic] |

Physical Activity

|Do you currently exercise? |Yes |No |

|If Yes, how often you do exercise? | |

| |..............days each week |

|Are you able to walk for 5 minutes without stopping? |Yes |No |

|If Yes, please tick how long can you walk for without stopping. | 5- 10 minutes |

| |10 – 20 minutes |

| |21 – 30 minutes |

| |31 – 40 minutes |

| |41 – 50 minutes |

| |51 – 60 minutes |

| |60 + minutes |

|If No, please tick how long can you walk for without stopping. | 0 – 1 minute |

| |1 – 2 minutes |

| |2 – 3 minutes |

| |3 – 4 minutes |

| |4 – 5 minutes |

|Are you able to perform your normal activities of daily living, i.e. put your clothes | | |

|on, climb stairs, go shopping, without getting out of breath or having a rest? |Yes |No |

Dietary History

|Do you enjoy eating chocolates? |Yes |No |

|If Yes, please circle how many bars/packets you have each week | |

|Normal size or Family Size |1-5 5-10 10-20 20-30 30-40 40+ |

| | |

|Do you enjoy eating biscuits? |Yes |No |

|If Yes, please state how many biscuits you have each day | |

| |each day |

|Do you enjoy eating sweets? |Yes |No |

|If Yes, please state how many medium sized packets you have each day | |

| |each day |

|Do you enjoy drinking Fizzy pop? |Yes |No |

|If Yes, please state how many litres you have each day | |

| |litres each day |

|Do you enjoy eating savoury snacks (pies, sausage rolls)? |Yes |No |

|If Yes, please state how many you eat each day | |

| |each day |

| | |

|Do you tend to eat large portions? |Yes |No |

|Do you tend to graze on foods? |Yes |No |

|Do you enjoy eating take aways? |Yes |No |

Which food or food group, do you think has contributed to your weight gain?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………

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