Bariatric Questionnaire

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Comments

This field is for validation purposes and should be left unchanged.

GENERAL

Name*

Prefix First Last

Email*

Date of Birth*

Gender*

Female

Male

Non-binary

What is your main reason for considering surgery?*

Insufficient Weight Loss

Weight Regain (after prior bariatric surgery)

Vomiting or Severe Reflux

Height (cm):*

Current Weight (kg):*

Maximum Weight (kg):*

Have you had prior Bariatric Surgery?*

Yes

If YES, please confirm which type:

Band

Bypass

Sleeve

Year of Prior Bariatric Surgery?

Maximum Weight (kg):

Why did you choose Dr Ian Martin*

Friend referred

GP recommendation

Website

DIABETES

Answer N/A if it is not relevant to you.

Have you ever received treatment for Diabetes?*

YES

N/A

Comments

Have you been diagnosed and treated for Type 2 Diabetes?*

YES

N/A

Comments

Have you ever been told you were “Pre-Diabetic”?*

YES

N/A

Comments

Is your Diabetes treated by Insulin injections?*

YES

N/A

Comments

Is your Diabetes treated with oral medication?*

YES

N/A

Comments

Is your Diabetes treated by diet only?*

YES

N/A

Comments

Answer N/A if it is not relevant to you. Please add number: Never controlled – 1, Somewhat controlled - 2, Usually controlled - 3, Always controlled - 4

Over the last 7 days, how controlled are your blood sugars?*

Controlled

N/A

Number:

AIRWAYS/SLEEP

Answer N/A if it is not relevant to you. Please add number: Never – 1, Sometimes - 2, Most of the time - 3, All the time - 4

Are your airways normal, breathing comfortably while you sleep?*

YES

N/A

Number:

Do you snore loudly?*

YES

N/A

Number:

Do you stop breathing while you sleep?*

YES

N/A

Number:

Do you choke while you sleep?*

YES

N/A

Number:

Have you ever been diagnosed with Obstructive Sleep Apnoea (OSA)?*

YES

N/A

Number:

Have you ever required the use of a CPAP or mouth splint?*

YES

N/A

Number:

CARDIOVASCULAR

Answer N/A if it is not relevant to you.

Have you ever been told your blood pressure was a little high?*

YES

N/A

Comments

Have you ever been diagnosed with heart disease?*

YES

N/A

Comments

Have you taken medication for elevated blood pressure?*

YES

N/A

Comments

Answer N/A if it is not relevant to you Dose Increased -1, Dose reduced - 2, Medication ceased - 3, Unchanged - 4

Was the dose ever reduced or the medication ceased?*

YES

N/A

Number:

Was the dose ever reduced or the medication ceased?*

YES

N/A

Comments

REFLUX /REGURGITATION

Answer N/A if it is not relevant to you. Please add number: Never – 1, Sometimes - 2, Most of the time - 3, All the time - 4

Do you ever have trouble with food or fluid coming up into your mouth?*

YES

N/A

Number:

Have you ever had acid or bile coming up into your mouth?*

YES

N/A

Comments

REFLUX / HEARTBURN

Answer N/A if it is not relevant to you. Please add number: Never - 1, Some Days -2, Most Days - 3, Everyday - 4

Have you ever suffered from reflux or heartburn?*

YES

N/A

Number:

Have you ever been prescribed medication for reflux?*

YES

N/A

Which medication:

Ever been diagnosed with Barrett’s Oesophagus?*

YES

N/A

Comments

Does the medication control your reflux?*

YES

N/A

Comments

Answer N/A if it is not relevant to you Dose increased - 1, Dose reduced - 2, Medication ceased - 3, Unchanged - 4

Has your dose ever been reduced or medication ceased?*

YES

N/A

Number:

HORMONAL

Answer N/A if it is not relevant to you.

Have you ever had infertility issues?*

YES

N/A

Improved?

YES

Female - Have you ever been diagnosed with PCOS?*

YES

N/A

Improved?

YES

Male - Have you ever had erectile dysfunction?*

YES

N/A

Improved?

YES

ECONOMIC

Answer N/A if it is not relevant to you. Please add number: Never – 1, Sometimes - 2, Most of the time - 3, All the time - 4

Do you feel your weight prevented you from getting appropriate employment?*

YES

N/A

Number:

Do you feel you are overlooked or discriminated against in the workplace?*

YES

N/A

Comments

HEALTH STATUS

Answer N/A if it is not relevant to you. Please add number: Never – 1, Sometimes - 2, Most of the time - 3, All the time - 4

Do you have problems dealing with everyday stress?*

YES

N/A

Number:

Do you ever feel sad about your weight?*

YES

N/A

Number:

Are you worried or anxious about your weight in relation to your general health?*

YES

N/A

Number:

DEPRESSION/ANXIETY

Answer N/A if it is not relevant to you. Please add number: Never – 1, Sometimes - 2, Most of the time - 3, All the time - 4

Have you ever suffered from depression or anxiety?*

YES

N/A

Number:

Are you taking any medication for depression and/or anxiety?*

YES

N/A

Which medication:

Answer N/A if it is not relevant to you Dose increased - 1, Dose reduced - 2, Medication ceased - 3, Unchanged - 4

Has your dose been decreased or medication ever been ceased?*

YES

N/A

Number:

BODY IMAGE

Answer N/A if it is not relevant to you. Please add number: Never – 1, Sometimes - 2, Most of the time - 3, All the time - 4

Are you troubled by your appearance?*

YES

N/A

Number:

FUNCTIONAL

Please add number: Fit - 4, Moderately Fit - 3, Somewhat Fit - 2, Moderately Unfit - 1, Unfit - 0

How would you describe your fitness? Number:*

LEISURE AND SOCIAL ACTIVITIES

Answer N/A if it is not relevant to you. Please add number: Never – 1, Sometimes - 2, Most of the time - 3, All the time - 4

Do you AVOID taking part in leisure/recreational activities?*

YES

N/A

Number:

KIDNEYS FUNCTION

Do you have normal kidney function?*

YES

Comments

Have you been diagnosed with kidney disease with loss of function?*

YES

Comments

LIVER FUNCTION

Do you have normal liver function?*

YES

Comments

Have you been diagnosed with liver disease?*

YES

Comments

Brisbane Weight Loss Surgery - helping you achieve a healthier lifestyle.

GENERAL

DIABETES

AIRWAYS/SLEEP

CARDIOVASCULAR

REFLUX /REGURGITATION

REFLUX / HEARTBURN

HORMONAL

ECONOMIC

HEALTH STATUS

DEPRESSION/ANXIETY

BODY IMAGE

FUNCTIONAL

LEISURE AND SOCIAL ACTIVITIES

KIDNEYS FUNCTION

LIVER FUNCTION

Brisbane Weight Loss Surgery

Scheduling an appointment is an important first step towards sustainable weight loss and a healthier, brighter future.