4269 EMPOWER SUBSEQUENT FOLLOW UP 190522 (1)

3/6/9/12 Month Follow-Up Visit Questionnaire
Select one:

Cash pay Contract/insured
Name:
Today's Date:

Month Day Year
Date
Date of Surgery

Month Day Year
Date
Date of Birth:

Month Day Year
Date
Problems:
Last 3 days tracked in Baritastic:

Calories (day 1):   Protein g (day 1):   Carb g (day 1):   Fat g (day 1):

Calories (day 2):   Protein g (day 2)   Carb g (day 2)   Fat g (day 2)

Calories (day 3):   Protein g (day 3)   Carb g (day 3)   Fat g (day 3)
Are you currently smoking?

Yes No
If yes, packs/day:
Quit Date:

Month Day Year
Date
Constipation:

Yes No
Diarrhea:

Yes No
Medications used/how often:
Reflux:

Yes No
If yes, please rate:
Medications used/how often:
# Steps/day:
Have you noticed an increase in alcohol/drug/gambling/spending/sex in your life?

Yes No
When you look in the mirror, what do you see?
Using CPAP/BiPAP

Yes No
Changes in CPAP/BiPap (ex. reduced blood pressure):
Are you monitoring glucose at home?

Yes No
Approximate glucose range:
Are you monitoring blood pressure at home?

Yes No
Approximate BP range:
Have you seen your primary care provider since surgery?

Yes No
List any medications stopped for diabetes/reflux/high blood pressure/high cholesterol:
Should be Empty:

3/6/9/12 Month Follow-Up Visit Questionnaire