PRE-OPERATIVE BARIATRIC PSYCHOSOCIAL ASSESSMENT

PRE-OPERATIVE BARIATRIC PSYCHOSOCIAL ASSESSMENT
DESA Holistic Wellbeing in collaboration with Better Life Surgery
This assessment forms part of your pre-operative counselling for bariatric surgery. It supports understanding your emotional wellbeing, readiness for surgery, and post-operative support needs.
A brief clinical summary will be shared with your bariatric surgeon.
SECTION 1 — CLIENT DETAILS
Full Name
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Planned Bariatric Procedure (if known)
Proposed Surgery Date (if known)

MonthDayYear
Date
SECTION 2 — INFORMED CONSENT
Please read and confirm the following:*

I understand this assessment is part of my pre-operative bariatric counsellingI understand this is a psychosocial readiness assessment, not a psychiatric diagnosis
I consent to a clinical summary of this assessment being shared with my bariatric surgeon
I understand my responses will be discussed during my counselling session
SECTION 3— EMOTIONAL WELLBEING SCREENING (DASS-21– SELECT ITEMS)
Below are statements about how you have been feeling over the past week.
Please select the option that best describes your experience.
Scale description below:
0 = Did not apply to me at all
1 = Applied to me to some degree
2 = Applied to me a considerable degree
3 = Applied to me very much
Each item below = Place a number in the box from the options above
I found it hard to wind down
I felt down-hearted and blue
I felt nervous or anxious
I felt close to panic
I felt I had nothing to look forward to
I felt scared without a good reason
I found it difficult to relax
(Clinical note: This tool is used as a screening measure only and does not provide a diagnosis.)
SECTION 4 — RELATIONSHIP WITH FOOD & EATING PATTERNS
Field type: Scale Rating
Scale: Never / Sometimes / Often / Always
Questions below answer with one of the following: Never / Sometimes / Often / Always
I eat in response to emotions rather than hunger
I eat when I am stressed, overwhelmed, or upset
I experience loss of control around food
I feel guilt, shame, or regret after eating
SECTION 5 — BODY IMAGE & SELF-PERCEPTION
Please complete the following scale:
Scale: Strongly Disagree / Disagree / Neutral / Agree / Strongly Agree
My weight has significantly affected how I feel about myself

Strongly disagreeDisagreeNeutralAgreeStrongly Agree
I avoid social situations due to my body or weight

Strongly disagreeDisagreeNeutralAgreeStrongly Agree
I believe surgery will improve my quality of life

Strongly disagreeDisagreeNeutralAgreeStrongly Agree
SECTION 6 — READINESS & EXPECTATIONS
Questions. Please answer truthfully:
What are your main reasons for choosing bariatric surgery at this time?
What changes do you expect emotionally and psychologically after surgery?
What does “success” look like for you after surgery?
SECTION 7 SUPPORT SYSTEM & AFTERCARE
Questions below:
Who will be your main supports during recovery?
Have you discussed surgery with family or close supports?
Are there any current stressors that may impact your recovery?
SECTION 8 — RISKS, COPING & AWARENESS
What concerns or fears do you have about surgery or life after surgery?
How do you usually cope when things feel difficult or overwhelming?
Have you experienced significant mental health challenges in the past?
SECTION 9 — FINAL ACKNOWLEDGEMENT
Field type: Checkbox (Required)*

I confirm the information provided is accurate to the best of my knowledgeI understand this assessment will be reviewed with my counsellor
Thank you for completing this assessment.
Your counsellor will review your responses prior to your session and discuss next steps with you.
Signature before submission

Clear
Should be Empty:

PRE-OPERATIVE BARIATRIC PSYCHOSOCIAL ASSESSMENT

SECTION 1 — CLIENT DETAILS

SECTION 2 — INFORMED CONSENT

SECTION 3— EMOTIONAL WELLBEING SCREENING (DASS-21– SELECT ITEMS)

SECTION 4 — RELATIONSHIP WITH FOOD & EATING PATTERNS

SECTION 5 — BODY IMAGE & SELF-PERCEPTION

SECTION 6 — READINESS & EXPECTATIONS

SECTION 7 SUPPORT SYSTEM & AFTERCARE

SECTION 8 — RISKS, COPING & AWARENESS

SECTION 9 — FINAL ACKNOWLEDGEMENT