Bariatric surgery patient questionnaire

1. Personal information

Full name

Date of birth

Email

Phone

Country & City

Current weight

Height

BMI

2. Your lifestyle

What is your profession, work environment, stress level?

How does your daily ‘eating routine’ approximately look like?

Have you tried to manage your weight with balanced, regular, healthy diet? When, did it work and for how long?

Do you find time for regular physical activities? What kind of them?

3. Do you have any disease? (Name, if Yes)

4. Have you had any disease recently?

5. Do you take any medicines on regular basis? (If Yes, what type)

6. Have you taken any other medicines recently? (If Yes, what type)

7. Name(s) of any previous operations? (Date performed)

8. Have you or any blood relative had any complications due to a previous anaesthetics?

9. Have you ever had blood transfusion? Did you have any complications?

Do you have or have you ever had?

10. Muscle disease, muscle weakness?

No

Yes

11. Heart or blood vessel problems?

No

Yes

12. Pulmonary and pipe disease (asthma, chronic bronchitis, pneumonia, tuberculosis, etc.)

No

Yes

13. Nerve system diseases? (Meningitis, encephalitis, multiple sclerosis, Parkinson’s disease, Epilepsy, convulsion attack, arachnoids)

No

Yes

14. Liverdiseases?

No

Yes

15. Eye diseases?

No

Yes

16. Articular diseases? (Rheumatism, polyarthritis)

No

Yes

17. Metabolic diseases? (Diabetes, thyroiddiseases)

No

Yes

18. Gastric and intestinal canal diseases? (Duodenal ulcer)

No

Yes

19. Blood and fibrillation disorder?

No

Yes

20. Have any of your blood relatives have fibrillation disorder?

No

Yes

21. Allergy? (To medicaments, to household chemistry, to pollen, to food-products)

No

Yes

22. Do you have any other here not mentioned disease?

No

Yes

23. Do you smoke?

No

Yes

24. Do you wake up at night?

No

Yes

26. Have you ever had burning in oesophagus, stomach?

No

Yes

27. For women – Is there any possibility that you are pregnant?

No

Yes

28. Have you got Covid-19 vaccine / or have been infected? When?

No

Yes

Privacy information:

With this questionnaire we collect data in order to provide professional, information based medical advise. The personal data of the person will be used only for informational purpose for the Sigulda Hospital (“Siguldas slimnica” Ltd, registration number 40003124730) bariatric team, related to the potential performance of the medical treatment.

PATIENT QUESTIONNAIRE