Bariatric Questionnaire
| 1. Have you had any other operations? | NO | YES |
| If YES, – What operations? – Have you had any post-operative complications? – If YES, please indicate them? |
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| 2. Have you had any anaesthesia? | NO | YES |
| If YES: – What kind? (general/spinal/epidural/regional)? – Have you had any complications after or during the anaesthesia? – If YES, please indicate them? |
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3. Do you have any metabolism disorders, such as Diabetes, or any vital organ diseases(cardiovascular, kidney, liver, digestive organ, lung, thyroid, nervous system)? |
NO | YES |
| If YES, please indicate them? | ||
| 4. Do you have any acute or chronic diseases (e.g. Hepatitis, AIDS)? | NO | YES |
| If YES, please indicate them? | ||
| 5. Have you ever experienced any allergic reactions to plaster, latex, medications, food? | NO | YES |
| 6. Have your earlier operations or injuries (for example during a visit to the dentist) ever caused any excessive bleeding or blood loss? | NO | YES |
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7. Do you have any blood diseases or tendency towards bleeding (e.g. frequent epistaxis, tendency towards subcutaneous bruises)? |
NO | YES |
| 8. Did your wound healing process ever complicate with abscesses, fistulas, severe scars? | NO | YES |
| 9. Do you have vein varicosis in legs? | NO | YES |
| 10. Do your teeth wobble? | NO | YES |
| 11. Have you ever experienced thrombosis or embolism? | NO | YES |
| 12. Do you take any medications constantly (aspirin, hormones)? | NO | YES |
| If YES, please indicate them? | ||
| 13. Do you smoke? | NO | YES |
| If YES, how many cigarettes per day? | ||
| 14. Do you drink alcohol regularly? | NO | YES |
| If YES, what kind and how much per day? | ||
| 15. Do you take drugs? | NO | YES |
| If YES: – How often and what kind of drug? |
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| 16. Question addressed to women of childbearing age: Will the operation coincide with your menstruations? |
NO | YES |
| 17. Is there any possibility that you are pregnant at the moment? | NO | YES |
How often do you eat the following foods? Please tick a relevant box:
| Every day | Every week | Every month | Never | |
| Meat | | | | |
| Fish | | | | |
| Eggs | | | | |
| Whole Wheat bread | | | | |
| Vegetables | | | | |
| Pasta | | | | |
| Rice | | | | |
| Potatoes | | | | |
| Hot Spicy Foods | | | | |
| Pizza | | | | |
| Burgers | | | | |
| Chips | | | | |
| Crisps | | | | |
| Ice Cream | | | | |
| Chocolate | | | | |
| Cake | | | | |
| Fizzy Drinks | | | | |
| Cheese | | | | |
| Coffee | | | | |
| Alcohol | | | | |
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