4269 EMPOWER SUBSEQUENT FOLLOW UP 190522 (1)

3/6/9/12 Month Follow-Up Visit Questionnaire
Cash payContract/insured
Name:
Today's Date:

MonthDayYear
Date
Date of Surgery

MonthDayYear
Date
Date of Birth:

MonthDayYear
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)
YesNo
If yes, packs/day:
Quit Date:

MonthDayYear
Date
YesNo
YesNo
Medications used/how often:
YesNo
If yes, please rate:
Medications used/how often:
# Steps/day:
YesNo
When you look in the mirror, what do you see?
YesNo
Changes in CPAP/BiPap (ex. reduced blood pressure):
YesNo
Approximate glucose range:
YesNo
Approximate BP range:
YesNo
List any medications stopped for diabetes/reflux/high blood pressure/high cholesterol:
Should be Empty:

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