Coastal Center for Obesity, Lap Band, Gastric Bypass, Bariatric Surgery, Weight Loss in Los Angeles and Orange County Call 888-527-5222 for Consultation
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Patient Support

Online Follow Up Form

6 Month Follow Up Form
Name
Please provide the full name, address and phone number of your family physician:
Physician Name
Address
City
State
Zip
Phone
   
Current Weight
For the following questions, answer "Yes" if they occur 3 or more days a week–otherwise answer "No".
Do you eat breakfast? Yes     No
Do you snack at night? Yes     No
Do you snack during the day? Yes     No
Do you drink soda or other very sugary liquids? Yes     No
Do you eat desserts and fried foods? Yes     No
Are the meals that you eat small, medium, or large as compared to normal weight people eating the same meal?
How many days a week do you exercise? Answer with a number even if you have to estimate.
How many cigarettes (packs) do you smoke a day?
Do you drink alcohol?
Have you been treated in an alcohol rehabilitation program? Yes     No
Do you use any recreational drugs? (“Yes” means once a month or more) Yes     No
Have you been treated in a drug rehabilitation program? Yes     No
Have you seen a psychiatrist since surgery? Yes     No

If seen by a Psychiatrist, please provide their name, address and phone number:

Psychiatrist Name
Address
City
State
Zip
Phone
Have you been hospitalized for psychiatric reasons? Yes     No
Are you employed? Yes     No
Are you satisfied with your social life? Yes     No
With regards to your body weight, how do you now see yourself as being?
Using the same criteria, how do you believe that others perceive you?
Are you satisfied with your sex life? Yes     No
How would you rate your self esteem level now?
Overall, how would you rate the quality of your life as compared to before surgery?
Based on how you feel now, would you have surgery again? Yes     No
Have you been diagnosed or treated for Diabetes? Yes     No
If yes, were you prescribed medication?
Have you been diagnosed or treated for High Blood Pressure? Yes     No
If yes, were you prescribed medication?
Have you been diagnosed or treated for Asthma? Yes     No
If yes, were you prescribed medication?
For the following questions, answer “Yes” if they occur 2 or more days a week–otherwise answer “No”.
Do you have heartburn? Yes     No
Do you have swelling of ankles? Yes     No
Do you have shortness of breath after climbing one flight of stairs? Yes     No
Do you have joint pain - back? Yes     No
Do you have joint pain - hip? Yes     No
Do you have joint pain - knee? Yes     No
Do you have joint pain - ankle? Yes     No
Do you have joint pain - foot? Yes     No
Do you have restless sleep or frequent awakening? Yes     No
Do you have night sweats? Yes     No
Do you snore? Yes     No
Do you have daytime sleepiness? Yes     No
Do you have morning headaches? Yes     No
Do you lose small amounts or urine with coughing or straining? Yes     No
In the past year, has anyone told you that you held your breath for a long time while asleep? Yes     No
Menstrual difficulties?
Have any other medical problems developed? Yes     No
Describe:
How would you rate your energy level?
Comments:
   

If you have filled out all of the answers to the best of your knowledge click the Submit button below.