4268 EMPOWER 1 MONTH FOLLOW UP 190522

Initial/1 Month Post Op Follow-Up Visit Questionnaire
Name:
Today's Date:

Month Day Year
Date
Date of Surgery

Month Day Year
Date
Date of Birth:

Month Day Year
Date
Problems:
Weight Loss Goal:
Intake: Fluids
ounces/day
Intake: Protein
grams/day
Stage of diet (select one):

full fluids puree soft foods regular diet
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):

Alcohol (what and how often):
Are you currently smoking?

Yes No
If yes, how many packs/day?
Pain (On a scale of 1-10, 10 being severe):
Location of pain:
Pain medications used/how often:
Nausea:
Nausea medications used/how often:
Vomiting:

Yes No
If yes, how many times per day?
Medications used/how often:
Constipation:

Yes No
Diarrhea:

Yes No
# Bowel movements since surgery:
Medications used/how often: