Bariatric Surgery Follow-up Form

Full Name*

Date of birth *

Country of Residence*

Phone Number*

Email *

Desired Procedure(s)*

Your Current Weight*

Maximum Weight Reached*

Your Height (in cm)*

Your Waist Circumference (in cm)*

Duration of Obesity*

What are your eating habits (sweet, salty, large meals, snacking, alcohol, sugary drinks, etc.)?*

Do you have any associated medical conditions (Diabetes, Hypertension, coronary insufficiency, endocrine diseases, joint diseases, sleep apnea, respiratory diseases, cancers, infertility, psychiatric illnesses, others...)? Please specify.*

Do you have any digestive diseases (gastroesophageal reflux, ulcer, cirrhosis, Crohn's disease, tumors, others...)? Please specify.*

Are you on any long-term medication? Please specify.*

Do you have any allergies (medication, others...)? Please specify.*

Have you already had surgical procedures? Please specify (type, method, etc.).*

Have you already had surgical procedures for obesity? Please specify (date, type, method, result, complications, etc.).*

Family Medical History*

Were there any complications after the first bariatric surgery?*

Yes

No

If yes, what were the complications, what was the treatment, and what were the results?

Weight before the first surgery*

Lowest weight reached after the first surgery and when*

What was the effect of this first surgery on any associated medical conditions?

Did you have follow-up with a nutritionist?*

Yes

If no, why not?

Did you have psychological follow-up?*

Medical File (Surgical report of the first procedure + Recent nutritional evaluation by a nutritionist with an assessment of caloric intake and meal volume + Abdominal CT scan with gastric volumetry + Recent fibroscopy)

Bariatric Surgery Follow-up Form

Bariatric Surgery Revision Form