Gastric Bypass Pre-Surgical Psychological Evaluation Intake Form
7015 W Deschutes Ave Suite B Kennewick, WA 99336
This intake form is a critical part of your evaluation. Please complete it to the best of your ability
(estimated time to complete 20min)
Today's date (MM/DD/YY)
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Name
*
First Name
Last Name
Gender
Female
Male
Non-binary
Email
*
example@example.com
Date of Birth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Can we leave messages at the cell phone number provided?
Yes
No
Marital Status
Occupation
Currently living with
No. Children and ages
Military service?
Yes (past)
No
Current
No. Years Education and degree
Emergency Contact: Name
*
Emergency Contact: Phone
*
MAIN CONCERNS: Please list the major reasons that you are seeking gastric bypass surgery, and rate the importance of each reason, according to the scale below:
Not Important 1----2----3-----4----5-----6----7----8----9----10 Extremely Important
Reason #1
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RATING
*
Reason #2
*
RATING
*
Reason #3
*
RATING
*
How long have you been considering bariatric surgery?
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Have you done any research regarding bariatric surgery?
Yes
No
If yes, where did you get your information?
Do you know anyone who has had bariatric surgery?
Yes
No
If yes, who?
Don't use names, just relationship to you (friend, cousin, coworker, etc)
HEALTH CARE PROVIDERS
PRIMARY CARE (PCP)
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Orthopedic
Psychologist/Therapist
Psychiatrist
Other (please specify)
Have you had any operations?
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Yes
No
If yes, please list date and type of operations
Have you had any major injuries, accidents, or broken bones?
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Yes
No
If yes, please list date and type of accident(s)
Have you been hospitalized for anything other than an operation or medical procedure?
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Yes
No
If yes, please describe date and reason for hospitalization?
Please list any medications you are currently taking (both prescribed or over the counter)
*
Include vitamins and inhalers
Please list any allergies or adverse reactions you have to medications:
WEIGHT HISTORY
DIETING HISTORY
Age you first started dieting:
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Weight Loss Programs you've used in the past? (select all that apply)
Jenny Craig
Nutri-Systems
Weight Watchers
Factor 75
Opti-fast Mefi Fast
O.A. or TOPS
Fen/Phen Redux
Meridia
Xenical
Over the Counter diet aids
Atkins Diet
South Beach Diet
If program not listed, please enter here
Please describe dates and types of weight loss programs you used?
Amount of weight loss? If no weight loss, explain
Did you consult with a health provider either before or after trying a program?
What was the most successful weight loss that you have achieved and how did you do it?
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What behaviors did you learn from dieting that you still use today?
NUTRITION AND FOOD HISTORY
What do you eat regularly?
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Breakfast
Mid-Morning snack
Lunch
Mid-afternoon snack
Dinner
After dinner snack
Dessert
On average, how often do you eat out each week?
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On average, what size portions do you normally have?
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Small
Moderate
Large
Extra Large
Uncertain
On average, how often do you eat more than one serving?
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Always
Usually
Sometimes
Never
On average, how long does it usually take you to eat a meal?
How often do you eat dessert? (times per week)
What do you eat for dessert most often?
How many times do you eat fried food per week?
On average, do you eat while doing other activities? (e.g. watching tv, reading, listening to music, etc)
Yes
No
Can you stop eating tempting foods (i.e. cookies chips, cake, etc) one you start?
Yes
No
Other
Do you get up during the night to eat?
Yes
No
Do you have a pattern of overeating and then regretting this behavior?
Yes
No
When you snack, which of the following do you usually eat? (select all that apply)
*
Candy
Cookies and cake
Pretzels
Cheese/crackers
Fruit
Donuts
Soda/Diet Soda
Pastries
Peanuts/ mixed nuts
Granola or grain bars
Popcorn
Vegetables
Ice Cream
Milk, yogurt, dairy products
Other
How often have you eaten an unusually large amount of food (an amount most people would agree is unusually large) in a short period of time (e.g. during a 2 hour period)?
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Please Select
Never
Less than once per week
Once per week
2-5 times per week
More than 5 times per week
How often have you eaten an unusually large amount of food and felt you could not stop eating or control how much you ate?
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Please Select
Never
Less than once per week
Once per week
2-5 times per week
More than 5 times per week
How often have you eaten unusually large amounts of food in a short time and felt that your eating was out of control?
*
Please Select
Never
Less than once per week
Once per week
2-5 times per week
More than 5 times per week
How upset were you about the episodes where you ate unusually large amounts of food?
*
Please Select
Never
Less than once per week
Once per week
2-5 times per week
More than 5 times per week
How often have you made yourself vomit or tried other methods of avoiding weight gain (e.g. laxatives, diuretics, excessive exercise) after eating unusually large amounts of food?
*
Please Select
Never
Less than once per week
Once per week
2-5 times per week
More than 5 times per week
Exercise Status
How often do you get cardiovascular exercise for at least 20-30 minutes per session?
*
No regular program
1 time/week
2 times/week
3-4times/week
5+times/week
How active are you in a typical day?
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Very sedentary
Minimal Activity
Moderately Active
Quite active
Very Active
Briefly describe your exercise program:
Exercise Preferences
How active is your occupation?
*
Inactive/Sedentary
Light work (cleaning, light carpentry, etc)
Moderate work
Very Active/Heavy work (heavy lifting, lots of walking)
Which of the following activities would you be willing to do regularly? (select all that apply)
Aerobics
Active gardening
Backpacking
Baseball/Softball
Bicycycling
Cross Country Skiiing
Dancing
Downhill Skiing
Football
Golfing
Horseback riding
Hiking
Hockey
Jogging/Running
Martial arts
Mountain Climbing
Raquetball/Tennis
Rollerblading
Rope Skipping
Rowing
Skating
Soccer
Stair stepping
Stretching
Yoga
Swimming
Volleyball
Walking
Weight Training
Other
GOALS FOR BARIATRIC SURGERY
What are your goals related to the surgery?
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What is your greatest fear regarding the surgery?
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What is your greatest hope regarding the surgery?
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Which of the following people do you expect to support your efforts to lose weight following your surgery?
Spouse
Children
Sibling(s)
Parent(s)
Friends
Coworkers
Members of your church
Other
Which of the following people do you expect to oppose or undermine your efforts to lose weight following your surgery?
Spouse
Children
Sibling(s)
Parent(s)
Friends
Coworkers
Members of your church
Other
NOTE: After hitting submit, please call our office (509) 572-2126
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