Bariatric Surgery
[pic][pic]
|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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