University of Nevada School of Medicine
                                 Division of Bariatric Surgery
                                    Department of Surgery
                             1707 W. Charleston Blvd., Suite 160
                                    Las Vegas, NV 89102
                                    Phone: (702) 671-5150
                                     Fax: (702) 384-6493


Please complete a seven day food record prior to your appointment. Bring the food
diary to your dietary and surgical evaluations. The food diary should include:

                 1. amount and type of food
                 2. any fast food
                 3. all beverages


Telephone Number (work):____________________(home):_______________________


Referring Physician:_________________________________________

Physician’s Address:_________________________________________



Physician’s Phone Number:__________________________________________

Other Physicians that care for you:___________________________________________


How did you hear about us? (Internet, primary care physician, friend, etc.)

                                   Page 1 of 9

How long have you been considering weight loss surgery?

What have been your main sources of information about weight loss surgery?

Y /     N     Do you know other people that have had an operation for obesity?

Y   / N       Have those operations been successful?

Are your family and friends supportive of your decision to undergo an operation to help
you lose weight?

What are your main reasons for considering an operation to help you lose weight?

                                   DIET HISTORY

List the major diet programs that you have tried, including approximate dates and about
of weight lost.
          Program                         Date                       Weight Lost

Y   / N       Have you used Fen/Phen in the past?

Have you used any of the following to control your weight?

Y   /   N     Bingeing and purging
Y   /   N     Bingeing followed by food restriction
Y   /   N     Vomiting
Y   /   N     Laxitives
Y   /   N     Diuretics

                                       Page 2 of 9
                                 WEIGHT HISTORY

What is your lifetime maximum weight? _____________________ When? _________

Y   / N        Were you obese before puberty?

Fill out this time line of weight during your life as best as you can.
Please include any important personal events (i.e. pregnancy, marriage, etc.)

  Age       Maximum Weight                              Important Events

                                  CURRENT HABITS

How many carbonated beverages do you drink a day?______________ Diet/Regular

How many times a week do you eat out?__________ In a Fast Food restaurant?_______

How much water do you drink a day?_________________________________________

How much milk do you drink a day?_______________________ skim/ 1% / 2% / whole

How many cups of coffee do you drink a day?_______________ decaffeinated/regular

Do you drink alcoholic beverages? If yes, describe weekly intake.__________________

Who does the food shopping in your household?_________________________________

Who does the cooking in your household?______________________________________

How many meals a day do you eat?

Y   / N        Do you snack throughout the day? If yes, describe.__________________

Y   / N        Do you eat in the middle of the night?

How many calories do you think you eat a day?_________________________________

                                       Page 3 of 9
I feel that I am overweight because: (Check all that apply)

_____   I eat normal amounts of food but have an abnormal metabolism.
_____   I eat larger than normal amounts of food.
_____   I tend to eat sweets and high calorie snacks.
_____   Other:

Y    / N       Do you exercise regularly? If yes, describe.________________________

If not, what is the most strenuous physical activity that you do in a week?

Which of the following activities can you do without stopping to rest?

_____   walk to a building from a distant parking space
_____   climb one flight of stairs
_____   climb two flights of stairs
_____   none of the above

If you stop to rest, what are the main reasons you stop? (check all that apply)

_____   short of breath
_____   fatigue
_____   chest pain
_____   joint discomfort – circle which one(s): hip knee ankle
_____   back pain
_____   other:_____________________________________________________________

                                SURGICAL HISTORY

List any previous operations you have had:

        Operation                     Date                    Problems




                                        Page 4 of 9
List any hospitalizations you have had for an illness or accident not requiring surgery:


                                 MEDICAL HISTORY

Do you have now or have you ever had any of the following medical problems?

_____   Diabetes? How long?________________________________________________
_____   Sleep apnea. How long using CPAP/BIPAP?_____________________________
_____   Asthma
_____   Other lung or breathing problems
_____   Low back pain
_____   Arthritis or degenerative joint disease
_____   Hypertension (high blood pressure)
_____   Hernia (umbilical, groin, incisional)
_____   Gallstones
_____   Gastroesophageal reflux disease or frequent heartburn
_____   Stress incontinence (leak urine with coughing or laughing)
_____   Heart attack or angina (chest pain, pressure, or tightness)
_____   Irregular heart rhythm or palpitations
_____   Congestive heart failure
_____   Peripheral edema (swelling of the legs or ankles)
_____   High cholesterol
_____   High triglycerides
_____   Stroke
_____   Thyroid problems
_____   Gout
_____   Kidney of bladder problems
_____   Depression treated with medications and/or counseling
_____   Anxiety
_____   Psychiatric illness. What kind?________________________________________
_____   History of physical or sexual abuse
_____   Alcoholism
_____   Substance abuse
_____   Migraine headaches
_____   Blood clot or embolus
_____   Abnormal bleeding or bruising
_____   Blood transfusion

                                        Page 5 of 9
_____    Seizure or epilepsy
_____    Liver problems or hepatitis
_____    Cancer
_____    Rheumatic fever
_____    Tuberculosis
_____    Other (specify:)____________________________________________________

For women only:

Y    /   N     Have you had problems with significant anemia?
Y    /   N     Do you have a family history of osteoporosis?
Y    /   N     Do you plan on becoming pregnant?
Y    /   N     Are you post menopausal?

                         MEDICATIONS AND ALLERGIES

         Medication                   Dosage / Amount           Number of times taken

Y    / N     Have you taken steroids such as prednisone or cortisone in the last 6 months?

List all medications/medical products to which you have an allergic or bad reaction?

         Medication/medical product                         Type of reaction





                                        Page 6 of 9

Have you ever smoked?

____ Never.
____ Yes, but I quit ____ years ago, and smoked about ____ packs per day for ____ years.
____ Yes, I smoke ____ packs per day and have smoked for ____ years.

Do you drink alcoholic beverages?

____ Yes, I drink more than 7 drinks weekly.
____ Yes, but I drink less than 7 drinks weekly.
____ I used to drink, but I quit. I quit ____ years ago. I used to drink _____ drinks a week
     for ____ years.
____ No.

Y   /   N     Do you use recreational or illegal drugs?
              Specify type:

                                    FAMILY HISTORY

Do any of your blood relatives have the following problems?
Explain which relative(s) and type of problem in the space provided.

____ Heart disease

____ Diabetes

____ Lung Disease

____ Stroke

____ Kidney disease

____ Liver disease

____ Cancer

____ Rheumatoid arthritis

____ Alcoholism

____ Serious mental illness

                                      Page 7 of 9
____ Other illnesses that run in the family

Y   /   N     Have you or any of your blood relatives had a serious problem with anesthesia?
              Specify type:

List the approximate weights of all family members. (may also designate at normal, overweight,
or obese)

Maternal Grandmother __________               Paternal Grandmother __________

Maternal Grandfather __________               Paternal Grandfather __________

Mother __________                             Father __________

Sister(s)     __________, __________, __________, __________, __________

Brother(s)    __________, __________, __________, __________, __________

Children      __________, __________, __________, __________, __________

                                  GENERAL SYMPTOMS

Do you currently have any of the following symptoms?
____ chest pain
____ blackouts or periods of dizziness
____ palpitations or irregular heart beats
____ swelling in the ankles
____ shortness of breath when walking up one flight of stairs
____ chronic cough or sputum (phlegm) production
____ blood in your sputum
____ black or tarry stools
____ diarrhea
____ frequent or new constipation
____ temporary loss or blurring of vision
____ temporary weakness of one or more limbs
____ facial weakness or numbness
____ burning with urination or frequent urination
____ arthritis or severe joint pains
____ back pain
____ excessive bleeding following minor cuts or dental surgery
____ pregnancy
____ fever
____ weight gain or loss greater than 10 pounds in the past 3 months

                                      Page 8 of 9
                                      SOCIAL HISTORY

With whom do you live?

What is your occupation?

How many hours a day are you employed outside the home?

How many hours a day do you watch TV?

If you are disabled, it is because:

Could someone help care for you if you were seriously ill?

Are there people for whom you are the primary care giver?

What hobbies do you have that are important to you?

                     Thank you for completing this questionnaire.
          It will help your doctor understand your health more thoroughly.

                                         Page 9 of 9

To top