Secondary Self-Assessment before bariatric surgery

Welcome to the pre-surgery secondary Self-Assessment

Dato Dr. Tikfu Gee requires a secondary self-assessment be completed prior to surgery.

Question: I have already completed an assessment – why do I have to redo this assessment?

Answer: This is a more comprehensive form aimed at gathering further information and ensuring no information has been missed in the first assessment for initial approval. Sometimes, some information is missed when completing the first form. It could be you forgot, you misunderstood at the time or didn’t understand the importance of being completely open and honest in your responses.

Please complete the form below. It will take about 30-45 minutes.

- Step 1 of 13

SECTION 1 of 20: YOUR DETAILS

Your full name (as found on your passport) *

Gender *

Your current age *

Height in CM *

Weight in KG *

Your current BMI *

Use this online calculator https://tinyurl.com/y26y4ryx

What was your heaviest weight (in KG) *

SECTION 2 of 20: GENERAL CONDITIONS DISCLOSURE

Are you currently being treated by a doctor for any illness, medical condition or mental health condition? *

Please describe in detail the condition/s you are currently being treated for *

Do you have support from your GP to undergo bariatric surgery? *

Are you taking any regular medication? *

This includes any prescription or non-prescription medications including contraception

Please tell us what medications including dosages *

SECTION 3 of 20: GENERAL MEDICAL HISTORY DISCLOSURE

Have you EVER had a medical procedure, operation or accident *

This should include any event, no matter how major or minor

Please tell us about this including the year *

Do you or have you suffer from any of the following ailments? (Please select all that apply)

Allergies (eg. medication, food, environment)
Lung problems (eg. tuberculosis, pulmonary embolism, upper respiratory tract infection)
Wheezing/bronchitis/asthma
Diabetes
Thyroid disease
High blood pressure
Heart disease (eg. heart attack, heart surgery, murmurs, palpitations, angina, pacemaker, deep vein thrombosis)
Shortness of breath or chest pain on exertion
Stomach pains or ulcers
Hernia
Fits/blackouts/dizziness
Epilepsy
Nervous or mental health conditions (eg. anxiety, depression, severe or abnormal stress reaction)
Severe head or spinal injury resulting in hospitalization
Skin disorders/ dermatitis
Any form of cancer
Any muscular, joint or skeletal problems?
Any form of liver or gallbladder disease (eg. Hepatitis)
Any blood disease
Sleep disorders (eg. sleep apnoea)
None of the above

If you have selected ANY of the above, please provide further details, the specific issue, actions taken medically and medications taken *

Please provide the type of cancer and details *

Please include type of cancer and year.

Did you have or continue to have ongoing chemo or radiotherapy? *

Please provide details of previous/ongoing chemotherapy or radiotherapy *

Please include all details

Please disclose any other health problems past or present not listed

SECTION 4 of 20: ANAESTHETIC HISTORY DISCLOSURE

Have you ever been subject to Anaesthesia? *

Please provide the date (or close estimate - month and year) *

Did you have previous anesthetic complications (nausea, vomiting, difficulty of intubation, etc.)? *

Please provide details of anesthetic complications *

SECTION 5 of 20: SURGICAL/PROCEDURE HISTORY DISCLOSURE

Past Surgical History *

No previous surgery
Lap Band
Stomach
Gall bladder
Abdominal Hernia
Caesarean
Uterus/Ovaries
Appendix
Small bowel removal
Colon surgery
Other

Please provide details of 'other' surgery *

Did you have any complications (minor or major) related to the surgery? *

Please describe the complication *

Do you or have you at any time suffered from *

Convulsions
Stroke & transient ischemic attacks
Psychiatric problem
Chronic pain problem
Depression. Please state medication (if taking)
Other
None of these

Please provide any medications being taken for these conditions *

SECTION 6 of 20: CARDIOVASCULAR DISCLOSURE

Cardiac: Do you or have you suffered from (select all that apply) *

High blood pressure
Heart attack
Chest pain
Cardiac failure
Heart valve disease
Pacemaker
Deep vein thrombosis
Other
No cardiovascular disease

Cardiac: Please provide details of 'other' *

SECTION 7 of 20: RESPIRATORY DISCLOSURE

Respiratory: Do you or have you suffered from (select all that apply) *

No respiratory disease
Asthma
Tuberculosis (TB)
Difficulty breathing
Sleep apnoea
Pulmonary embolism
Upper respiratory tract infection
Other

Please provide details of 'other' *

SECTION 8 of 20: SLEEP APONEA DISCLOSURE

Sleep Apnoea Diagnosis Tool

	Yes	No
Do you snore loudly ?	Do you snore loudly ? Yes	Do you snore loudly ? No
Feel tired or sleepy during daytime?	Feel tired or sleepy during daytime? Yes	Feel tired or sleepy during daytime? No
Stop breathing during your sleep?	Stop breathing during your sleep? Yes	Stop breathing during your sleep? No
Do you have high blood pressure?	Do you have high blood pressure? Yes	Do you have high blood pressure? No
BMI more than 35?	BMI more than 35? Yes	BMI more than 35? No
Age over 50 years old?	Age over 50 years old? Yes	Age over 50 years old? No
Neck circumference greater than 40cm	Neck circumference greater than 40cm Yes	Neck circumference greater than 40cm No
Gender male?	Gender male? Yes	Gender male? No

**Additional post operative care may be anticipated

If you have Sleep Aponea, are you using any of the following machines? *

No machine in use
CPAP
BIPAP
Other

Please tell us what machine you are using currently *

SECTION 9 of 20: LIVER/INTESTINE DISCLOSURE

Liver/Intestine: Do you suffer from *

No liver/intestinal disease
Liver disease (yellow skin and eyes, swelling of the liver)
Gastric/ stomach ulcer
Other

Please provide details of 'other' *

SECTION 10 of 20: ENDOCRINE DISCLOSURE

Endocrine: Do you suffer from *

No endocrine disease
Diabetes Mellitus
Thyroid disease
Other Endocrine issue

Please provide details of 'other' *

SECTION 11 of 20: RENAL/KIDNEY DISCLOSURE

Renal/Kidney: Do you suffer from *

No renal/kidney disease
Kidney disease
Dialysis
Other Renal/Kidney problem

Please provide details of 'other' *

SECTION 12 of 20: MEDICATIONS DISCLOSURE

Medications: Do you currently take *

Not taking any medication
Anticoagulant/ Antiplatelet
warfarin
aspirin
anti-coagulants
beta blockers
Oral contraceptive pills
Estrogen pills
Traditional medicine/herbs/supplements
Other

Please provide details of 'other' *

SECTION 13 of 20: ALLERGIES DISCLOSURE

Allergies: Do you currently suffer from allergies to *

No allergy
Drugs
Food
Environment (eg. dust, pollen)
Latex/rubber
Other

Please provide details of 'other' *

Please advise which specific drugs you have allergies to *

Please advise which specific foods you have allergies to *

SECTION 14 of 20: GENERAL QUESTIONS

Are you currently pregnant? *

For females, please provide your last period date

Do you smoke cigarettes? *

How many cigarettes per day do you smoke? *

Do you drink alcohol? *

Please advise the amount you drink per week *

Single Standard drink = 1 x can/stubbie beer, 1 x glass wine, 1 x measure spirits

Are you able to ambulate? (walk or move from place to place) *

When climbing stairs, at what point would you feel 'breathless'? *

How often do you exercise? *

SECTION 15 of 20: FAMILY MEDICAL HISTORY DISCLOSURE

Please select any family medical issues (select all that apply) *

Obesity
Diabetes
High blood pressure
Cancer
Heart disease
Other
None of these

Please advise about 'other' *

SECTION 16 of 20: CURRENT FOOD HABITS ASSESSMENT

It is important to be completely honest in these questions to enable the surgeon to understand your food habits.DIRECTIONS: Please describe what your typical food, drinks and snacks intake in your typical day looks like (type & portion sizes).

Breakfast *

eg. 1 egg, 1 slice of toast

Snacks (morning) *

eg. half tub yogurt, 1 handful of nuts. If none, enter 'none'

Lunch *

3-4 tbsp/tsp of pasta, 1 palm size chicken, 3 tbsp sauces

Snacks (afternoon) *

eg. half tub yogurt, 1 handful of nuts. If none, enter 'none'

Dinner *

eg. 100grams of steak + 2 cups of vegetables and gravy

Snacks (evening) *

eg. bowl icream, 2 x donuts, 1 bag of potato chips. If none, enter 'none'

Water intake per day *

Are you taking any health supplements *

What supplements do you take? *

SECTION 17 of 20: SLEEPINESS ASSESSMENT

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Answer this based on the days you had enough sleep.

Sitting and reading *

Not at all Likely Extremely Likely
0	1	2	3	4	5	6	7	8	9	10

Watching television *

Not at all Likely Extremely Likely
0	1	2	3	4	5	6	7	8	9	10

Sitting inactive in a public place (e.g: meeting or theater) *

Not at all Likely Extremely Likely
0	1	2	3	4	5	6	7	8	9	10

As a passenger in a car for an hour without a break *

Not at all Likely Extremely Likely
0	1	2	3	4	5	6	7	8	9	10

Lying down to rest in the afternoon when circumstances permit *

Not at all Likely Extremely Likely
0	1	2	3	4	5	6	7	8	9	10

Sitting and talking to someone *

Not at all Likely Extremely Likely
0	1	2	3	4	5	6	7	8	9	10

Sitting quietly after a lunch without alcohol *

Not at all Likely Extremely Likely
0	1	2	3	4	5	6	7	8	9	10

In a car, while stopped for a few minutes in the traffic *

Not at all Likely Extremely Likely
0	1	2	3	4	5	6	7	8	9	10

How many hours do you normally sleep? *

SECTION 18 of 20: YOUR QUALITY OF LIFE NOW

Please use the rating tools to answer the questions below

	1 Very poor	2	3	4	5 Very Good
1. How would you rate your quality of life?	1. How would you rate your quality of life? 1 Very poor	1. How would you rate your quality of life? 2	1. How would you rate your quality of life? 3	1. How would you rate your quality of life? 4	1. How would you rate your quality of life? 5 Very Good

	1 Very dissatisfied	2	3	4	5 Very Satisfied
2. How satisfied are you with your health?	2. How satisfied are you with your health? 1 Very dissatisfied	2. How satisfied are you with your health? 2	2. How satisfied are you with your health? 3	2. How satisfied are you with your health? 4	2. How satisfied are you with your health? 5 Very Satisfied

	1 Not at all	2	3	4	5 An extreme amount
3. To what extent do you feel that physical pain prevents you from doing what you need to do?	3. To what extent do you feel that physical pain prevents you from doing what you need to do? 1 Not at all	3. To what extent do you feel that physical pain prevents you from doing what you need to do? 2	3. To what extent do you feel that physical pain prevents you from doing what you need to do? 3	3. To what extent do you feel that physical pain prevents you from doing what you need to do? 4	3. To what extent do you feel that physical pain prevents you from doing what you need to do? 5 An extreme amount

	1 Not at all	2	3	4	5 An extreme amount
4. How much do you need any medical treatment to function in your daily life?	4. How much do you need any medical treatment to function in your daily life? 1 Not at all	4. How much do you need any medical treatment to function in your daily life? 2	4. How much do you need any medical treatment to function in your daily life? 3	4. How much do you need any medical treatment to function in your daily life? 4	4. How much do you need any medical treatment to function in your daily life? 5 An extreme amount

	1 Not at all	2	3	4	5 Very highly
5. How much do you enjoy life?	5. How much do you enjoy life? 1 Not at all	5. How much do you enjoy life? 2	5. How much do you enjoy life? 3	5. How much do you enjoy life? 4	5. How much do you enjoy life? 5 Very highly

	1 Not at all	2	3	4	5 Very meaningful
6. To what extent do you feel your life to be meaningful?	6. To what extent do you feel your life to be meaningful? 1 Not at all	6. To what extent do you feel your life to be meaningful? 2	6. To what extent do you feel your life to be meaningful? 3	6. To what extent do you feel your life to be meaningful? 4	6. To what extent do you feel your life to be meaningful? 5 Very meaningful

	1 Not at all	2	3	4	5 Very easily
7. How well are you able to concentrate?	7. How well are you able to concentrate? 1 Not at all	7. How well are you able to concentrate? 2	7. How well are you able to concentrate? 3	7. How well are you able to concentrate? 4	7. How well are you able to concentrate? 5 Very easily

	1 Not at all	2	3	4	5 Extremely safe
8. How safe do you feel in your daily life?	8. How safe do you feel in your daily life? 1 Not at all	8. How safe do you feel in your daily life? 2	8. How safe do you feel in your daily life? 3	8. How safe do you feel in your daily life? 4	8. How safe do you feel in your daily life? 5 Extremely safe

	1 Not at all	2	3	4	5 Very healthy
9. How healthy is your physical environment?	9. How healthy is your physical environment? 1 Not at all	9. How healthy is your physical environment? 2	9. How healthy is your physical environment? 3	9. How healthy is your physical environment? 4	9. How healthy is your physical environment? 5 Very healthy

	1 Not at all	2	3	4	5 Completely
10. Do you have enough energy for everyday life?	10. Do you have enough energy for everyday life? 1 Not at all	10. Do you have enough energy for everyday life? 2	10. Do you have enough energy for everyday life? 3	10. Do you have enough energy for everyday life? 4	10. Do you have enough energy for everyday life? 5 Completely

	1 Not at all	2	3	4	5 Completely
11. Are you able to accept your bodily appearance?	11. Are you able to accept your bodily appearance? 1 Not at all	11. Are you able to accept your bodily appearance? 2	11. Are you able to accept your bodily appearance? 3	11. Are you able to accept your bodily appearance? 4	11. Are you able to accept your bodily appearance? 5 Completely

	1 Not at all	2	3	4	5 Completely
12. Have you enough money to meet your needs?	12. Have you enough money to meet your needs? 1 Not at all	12. Have you enough money to meet your needs? 2	12. Have you enough money to meet your needs? 3	12. Have you enough money to meet your needs? 4	12. Have you enough money to meet your needs? 5 Completely

	1 Not at all	2	3	4	5 Completely
13. How available to you is the information that you need in your day-to-day life?	13. How available to you is the information that you need in your day-to-day life? 1 Not at all	13. How available to you is the information that you need in your day-to-day life? 2	13. How available to you is the information that you need in your day-to-day life? 3	13. How available to you is the information that you need in your day-to-day life? 4	13. How available to you is the information that you need in your day-to-day life? 5 Completely

	1 Not at all	2	3	4	5 Completely
14. To what extent do you have the opportunity for leisure activities?	14. To what extent do you have the opportunity for leisure activities? 1 Not at all	14. To what extent do you have the opportunity for leisure activities? 2	14. To what extent do you have the opportunity for leisure activities? 3	14. To what extent do you have the opportunity for leisure activities? 4	14. To what extent do you have the opportunity for leisure activities? 5 Completely

	1 Not at all	2	3	4	5 Very easily
15. How well are you able to get around?	15. How well are you able to get around? 1 Not at all	15. How well are you able to get around? 2	15. How well are you able to get around? 3	15. How well are you able to get around? 4	15. How well are you able to get around? 5 Very easily

	1 Very dissatisfied	2	3	4	5 Very satisfied
16. How satisfied are you with your sleep?	16. How satisfied are you with your sleep? 1 Very dissatisfied	16. How satisfied are you with your sleep? 2	16. How satisfied are you with your sleep? 3	16. How satisfied are you with your sleep? 4	16. How satisfied are you with your sleep? 5 Very satisfied

	1 Very dissatisfied	2	3	4	5 Very satisfied
17. How satisfied are you with your ability to perform your daily living activities?	17. How satisfied are you with your ability to perform your daily living activities? 1 Very dissatisfied	17. How satisfied are you with your ability to perform your daily living activities? 2	17. How satisfied are you with your ability to perform your daily living activities? 3	17. How satisfied are you with your ability to perform your daily living activities? 4	17. How satisfied are you with your ability to perform your daily living activities? 5 Very satisfied

	1 Very dissatisfied	2	3	4	5 Very satisfied
18. How satisfied are you with your capacity for work?	18. How satisfied are you with your capacity for work? 1 Very dissatisfied	18. How satisfied are you with your capacity for work? 2	18. How satisfied are you with your capacity for work? 3	18. How satisfied are you with your capacity for work? 4	18. How satisfied are you with your capacity for work? 5 Very satisfied

	1 Very dissatisfied	2	3	4	5 Very satisfied
19. How satisfied are you with yourself?	19. How satisfied are you with yourself? 1 Very dissatisfied	19. How satisfied are you with yourself? 2	19. How satisfied are you with yourself? 3	19. How satisfied are you with yourself? 4	19. How satisfied are you with yourself? 5 Very satisfied

	1 Very dissatisfied	2	3	4	5 Very satisfied
20. How satisfied are you with your personal relationships?	20. How satisfied are you with your personal relationships? 1 Very dissatisfied	20. How satisfied are you with your personal relationships? 2	20. How satisfied are you with your personal relationships? 3	20. How satisfied are you with your personal relationships? 4	20. How satisfied are you with your personal relationships? 5 Very satisfied

	1 Very dissatisfied	2	3	4	5 Very satisfied
21. How satisfied are you with your sex life?	21. How satisfied are you with your sex life? 1 Very dissatisfied	21. How satisfied are you with your sex life? 2	21. How satisfied are you with your sex life? 3	21. How satisfied are you with your sex life? 4	21. How satisfied are you with your sex life? 5 Very satisfied

	1 Very dissatisfied	2	3	4	5 Very satisfied
22. How satisfied are you with the support you get from your friends?	22. How satisfied are you with the support you get from your friends? 1 Very dissatisfied	22. How satisfied are you with the support you get from your friends? 2	22. How satisfied are you with the support you get from your friends? 3	22. How satisfied are you with the support you get from your friends? 4	22. How satisfied are you with the support you get from your friends? 5 Very satisfied

	1 Very dissatisfied	2	3	4	5 Very satisfied
23. How satisfied are you with the conditions of your living place?	23. How satisfied are you with the conditions of your living place? 1 Very dissatisfied	23. How satisfied are you with the conditions of your living place? 2	23. How satisfied are you with the conditions of your living place? 3	23. How satisfied are you with the conditions of your living place? 4	23. How satisfied are you with the conditions of your living place? 5 Very satisfied

	1 Very dissatisfied	2	3	4	5 Very satisfied
24. How satisfied are you with your access to health services?	24. How satisfied are you with your access to health services? 1 Very dissatisfied	24. How satisfied are you with your access to health services? 2	24. How satisfied are you with your access to health services? 3	24. How satisfied are you with your access to health services? 4	24. How satisfied are you with your access to health services? 5 Very satisfied

	1 Very dissatisfied	2	3	4	5 Very satisfied
25. How satisfied are you with your transport?	25. How satisfied are you with your transport? 1 Very dissatisfied	25. How satisfied are you with your transport? 2	25. How satisfied are you with your transport? 3	25. How satisfied are you with your transport? 4	25. How satisfied are you with your transport? 5 Very satisfied

	1 Never	2	3	4	5 Always
26. How often do you have negative feelings such as blue mood, despair, anxiety, depression?	26. How often do you have negative feelings such as blue mood, despair, anxiety, depression? 1 Never	26. How often do you have negative feelings such as blue mood, despair, anxiety, depression? 2	26. How often do you have negative feelings such as blue mood, despair, anxiety, depression? 3	26. How often do you have negative feelings such as blue mood, despair, anxiety, depression? 4	26. How often do you have negative feelings such as blue mood, despair, anxiety, depression? 5 Always

SECTION 19 of 20: YOUR ATTITUDE TOWARDS EATING

Please rate as honestly as possible

	1 Never	2	3	4	5	6 Always
1. Am terrified about being overweight.	1. Am terrified about being overweight. 1 Never	1. Am terrified about being overweight. 2	1. Am terrified about being overweight. 3	1. Am terrified about being overweight. 4	1. Am terrified about being overweight. 5	1. Am terrified about being overweight. 6 Always

	1 Never	2	3	4	5	6 Always
2. Avoid eating when I am hungry.	2. Avoid eating when I am hungry. 1 Never	2. Avoid eating when I am hungry. 2	2. Avoid eating when I am hungry. 3	2. Avoid eating when I am hungry. 4	2. Avoid eating when I am hungry. 5	2. Avoid eating when I am hungry. 6 Always

	1 Never	2	3	4	5	6 Always
3. Find myself preoccupied with food.	3. Find myself preoccupied with food. 1 Never	3. Find myself preoccupied with food. 2	3. Find myself preoccupied with food. 3	3. Find myself preoccupied with food. 4	3. Find myself preoccupied with food. 5	3. Find myself preoccupied with food. 6 Always

	1 Never	2	3	4	5	6 Always
4. Have gone on eating binges where I feel that I may not be able to stop.	4. Have gone on eating binges where I feel that I may not be able to stop. 1 Never	4. Have gone on eating binges where I feel that I may not be able to stop. 2	4. Have gone on eating binges where I feel that I may not be able to stop. 3	4. Have gone on eating binges where I feel that I may not be able to stop. 4	4. Have gone on eating binges where I feel that I may not be able to stop. 5	4. Have gone on eating binges where I feel that I may not be able to stop. 6 Always

	1 Never	2	3	4	5	6 Always
5. Cut my food into small pieces.	5. Cut my food into small pieces. 1 Never	5. Cut my food into small pieces. 2	5. Cut my food into small pieces. 3	5. Cut my food into small pieces. 4	5. Cut my food into small pieces. 5	5. Cut my food into small pieces. 6 Always

	1 Never	2	3	4	5	6 Always
6. Aware of the calorie content of foods that I eat.	6. Aware of the calorie content of foods that I eat. 1 Never	6. Aware of the calorie content of foods that I eat. 2	6. Aware of the calorie content of foods that I eat. 3	6. Aware of the calorie content of foods that I eat. 4	6. Aware of the calorie content of foods that I eat. 5	6. Aware of the calorie content of foods that I eat. 6 Always

	1 Never	2	3	4	5	6 Always
7. Particularly avoid food with high carbohydrate content (i.e. bread, rice, potatoes).	7. Particularly avoid food with high carbohydrate content (i.e. bread, rice, potatoes). 1 Never	7. Particularly avoid food with high carbohydrate content (i.e. bread, rice, potatoes). 2	7. Particularly avoid food with high carbohydrate content (i.e. bread, rice, potatoes). 3	7. Particularly avoid food with high carbohydrate content (i.e. bread, rice, potatoes). 4	7. Particularly avoid food with high carbohydrate content (i.e. bread, rice, potatoes). 5	7. Particularly avoid food with high carbohydrate content (i.e. bread, rice, potatoes). 6 Always

	1 Never	2	3	4	5	6 Always
8. Feel that others would prefer if I ate more.	8. Feel that others would prefer if I ate more. 1 Never	8. Feel that others would prefer if I ate more. 2	8. Feel that others would prefer if I ate more. 3	8. Feel that others would prefer if I ate more. 4	8. Feel that others would prefer if I ate more. 5	8. Feel that others would prefer if I ate more. 6 Always

	1 Never	2	3	4	5	6 Always
9. Vomit after I have eaten.	9. Vomit after I have eaten. 1 Never	9. Vomit after I have eaten. 2	9. Vomit after I have eaten. 3	9. Vomit after I have eaten. 4	9. Vomit after I have eaten. 5	9. Vomit after I have eaten. 6 Always

	1 Never	2	3	4	5	6 Always
10. Feel extremely guilty after eating.	10. Feel extremely guilty after eating. 1 Never	10. Feel extremely guilty after eating. 2	10. Feel extremely guilty after eating. 3	10. Feel extremely guilty after eating. 4	10. Feel extremely guilty after eating. 5	10. Feel extremely guilty after eating. 6 Always

	1 Never	2	3	4	5	6 Always
11. Am preoccupied with a desire to be thinner.	11. Am preoccupied with a desire to be thinner. 1 Never	11. Am preoccupied with a desire to be thinner. 2	11. Am preoccupied with a desire to be thinner. 3	11. Am preoccupied with a desire to be thinner. 4	11. Am preoccupied with a desire to be thinner. 5	11. Am preoccupied with a desire to be thinner. 6 Always

	1 Never	2	3	4	5	6 Always
12. Think about burning up calories when I exercise.	12. Think about burning up calories when I exercise. 1 Never	12. Think about burning up calories when I exercise. 2	12. Think about burning up calories when I exercise. 3	12. Think about burning up calories when I exercise. 4	12. Think about burning up calories when I exercise. 5	12. Think about burning up calories when I exercise. 6 Always

	1 Never	2	3	4	5	6 Always
13. Other people think that I’m too thin.	13. Other people think that I’m too thin. 1 Never	13. Other people think that I’m too thin. 2	13. Other people think that I’m too thin. 3	13. Other people think that I’m too thin. 4	13. Other people think that I’m too thin. 5	13. Other people think that I’m too thin. 6 Always

	1 Never	2	3	4	5	6 Always
14. Am preoccupied with the thought of having fat on my body.	14. Am preoccupied with the thought of having fat on my body. 1 Never	14. Am preoccupied with the thought of having fat on my body. 2	14. Am preoccupied with the thought of having fat on my body. 3	14. Am preoccupied with the thought of having fat on my body. 4	14. Am preoccupied with the thought of having fat on my body. 5	14. Am preoccupied with the thought of having fat on my body. 6 Always

	1 Never	2	3	4	5	6 Always
15. Take longer than others to eat my meals.	15. Take longer than others to eat my meals. 1 Never	15. Take longer than others to eat my meals. 2	15. Take longer than others to eat my meals. 3	15. Take longer than others to eat my meals. 4	15. Take longer than others to eat my meals. 5	15. Take longer than others to eat my meals. 6 Always

	1 Never	2	3	4	5	6 Always
16. Avoid foods with sugar in them.	16. Avoid foods with sugar in them. 1 Never	16. Avoid foods with sugar in them. 2	16. Avoid foods with sugar in them. 3	16. Avoid foods with sugar in them. 4	16. Avoid foods with sugar in them. 5	16. Avoid foods with sugar in them. 6 Always

	1 Never	2	3	4	5	6 Always
17. Eat diet foods.	17. Eat diet foods. 1 Never	17. Eat diet foods. 2	17. Eat diet foods. 3	17. Eat diet foods. 4	17. Eat diet foods. 5	17. Eat diet foods. 6 Always

	1 Never	2	3	4	5	6 Always
18. Feel that food controls my life.	18. Feel that food controls my life. 1 Never	18. Feel that food controls my life. 2	18. Feel that food controls my life. 3	18. Feel that food controls my life. 4	18. Feel that food controls my life. 5	18. Feel that food controls my life. 6 Always

	1 Never	2	3	4	5	6 Always
19. Display self-control around food.	19. Display self-control around food. 1 Never	19. Display self-control around food. 2	19. Display self-control around food. 3	19. Display self-control around food. 4	19. Display self-control around food. 5	19. Display self-control around food. 6 Always

	1 Never	2	3	4	5	6 Always
20. Feel that others pressure me to eat.	20. Feel that others pressure me to eat. 1 Never	20. Feel that others pressure me to eat. 2	20. Feel that others pressure me to eat. 3	20. Feel that others pressure me to eat. 4	20. Feel that others pressure me to eat. 5	20. Feel that others pressure me to eat. 6 Always

	1 Never	2	3	4	5	6 Always
21. Give too much time and thought to food.	21. Give too much time and thought to food. 1 Never	21. Give too much time and thought to food. 2	21. Give too much time and thought to food. 3	21. Give too much time and thought to food. 4	21. Give too much time and thought to food. 5	21. Give too much time and thought to food. 6 Always

	1 Never	2	3	4	5	6 Always
22. Feel uncomfortable after eating sweets.	22. Feel uncomfortable after eating sweets. 1 Never	22. Feel uncomfortable after eating sweets. 2	22. Feel uncomfortable after eating sweets. 3	22. Feel uncomfortable after eating sweets. 4	22. Feel uncomfortable after eating sweets. 5	22. Feel uncomfortable after eating sweets. 6 Always

	1 Never	2	3	4	5	6 Always
23. Engage in dieting behaviour.	23. Engage in dieting behaviour. 1 Never	23. Engage in dieting behaviour. 2	23. Engage in dieting behaviour. 3	23. Engage in dieting behaviour. 4	23. Engage in dieting behaviour. 5	23. Engage in dieting behaviour. 6 Always

	1 Never	2	3	4	5	6 Always
24. Like my stomach to be empty.	24. Like my stomach to be empty. 1 Never	24. Like my stomach to be empty. 2	24. Like my stomach to be empty. 3	24. Like my stomach to be empty. 4	24. Like my stomach to be empty. 5	24. Like my stomach to be empty. 6 Always

	1 Never	2	3	4	5	6 Always
25. Have the impulse to vomit after meals.	25. Have the impulse to vomit after meals. 1 Never	25. Have the impulse to vomit after meals. 2	25. Have the impulse to vomit after meals. 3	25. Have the impulse to vomit after meals. 4	25. Have the impulse to vomit after meals. 5	25. Have the impulse to vomit after meals. 6 Always

	1 Never	2	3	4	5	6 Always
26. Enjoy trying new rich food.	26. Enjoy trying new rich food. 1 Never	26. Enjoy trying new rich food. 2	26. Enjoy trying new rich food. 3	26. Enjoy trying new rich food. 4	26. Enjoy trying new rich food. 5	26. Enjoy trying new rich food. 6 Always

	Never	Once a month or less	2-3 times a month	Once a week	2-6 times a week	Once a day or more
27. Gone on eating binges where you feel that you may not be able to stop?	27. Gone on eating binges where you feel that you may not be able to stop? Never	27. Gone on eating binges where you feel that you may not be able to stop? Once a month or less	27. Gone on eating binges where you feel that you may not be able to stop? 2-3 times a month	27. Gone on eating binges where you feel that you may not be able to stop? Once a week	27. Gone on eating binges where you feel that you may not be able to stop? 2-6 times a week	27. Gone on eating binges where you feel that you may not be able to stop? Once a day or more

	Never	Once a month or less	2-3 times a month	Once a week	2-6 times a week	Once a day or more
28. Ever made yourself sick (vomited) to control your weight or shape?	28. Ever made yourself sick (vomited) to control your weight or shape? Never	28. Ever made yourself sick (vomited) to control your weight or shape? Once a month or less	28. Ever made yourself sick (vomited) to control your weight or shape? 2-3 times a month	28. Ever made yourself sick (vomited) to control your weight or shape? Once a week	28. Ever made yourself sick (vomited) to control your weight or shape? 2-6 times a week	28. Ever made yourself sick (vomited) to control your weight or shape? Once a day or more

	Never	Once a month or less	2-3 times a month	Once a week	2-6 times a week	Once a day or more
29. Ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape?	29. Ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape? Never	29. Ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape? Once a month or less	29. Ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape? 2-3 times a month	29. Ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape? Once a week	29. Ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape? 2-6 times a week	29. Ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape? Once a day or more

	Never	Once a month or less	2-3 times a month	Once a week	2-6 times a week	Once a day or more
30. Exercised more than 60 minutes a day to lose or control your weight?	30. Exercised more than 60 minutes a day to lose or control your weight? Never	30. Exercised more than 60 minutes a day to lose or control your weight? Once a month or less	30. Exercised more than 60 minutes a day to lose or control your weight? 2-3 times a month	30. Exercised more than 60 minutes a day to lose or control your weight? Once a week	30. Exercised more than 60 minutes a day to lose or control your weight? 2-6 times a week	30. Exercised more than 60 minutes a day to lose or control your weight? Once a day or more

31. Lost 20 pounds (9kg) or more in the past 6 months. *

SECTION 20 of 20: SELF ESTEEM

	1 Strongly Agree	2	3	4	5 Strongly Disagree
1. On the whole, I am satisfied with myself.	1. On the whole, I am satisfied with myself. 1 Strongly Agree	1. On the whole, I am satisfied with myself. 2	1. On the whole, I am satisfied with myself. 3	1. On the whole, I am satisfied with myself. 4	1. On the whole, I am satisfied with myself. 5 Strongly Disagree

	1 Strongly Agree	2	3	4	5 Strongly Disagree
2. At times I think I am no good at all.	2. At times I think I am no good at all. 1 Strongly Agree	2. At times I think I am no good at all. 2	2. At times I think I am no good at all. 3	2. At times I think I am no good at all. 4	2. At times I think I am no good at all. 5 Strongly Disagree

	1 Strongly Agree	2	3	4	5 Strongly Disagree
3. I feel that I have a number of good qualities.	3. I feel that I have a number of good qualities. 1 Strongly Agree	3. I feel that I have a number of good qualities. 2	3. I feel that I have a number of good qualities. 3	3. I feel that I have a number of good qualities. 4	3. I feel that I have a number of good qualities. 5 Strongly Disagree

	1 Strongly Agree	2	3	4	5 Strongly Disagree
4. I am able to do things as well as most other people.	4. I am able to do things as well as most other people. 1 Strongly Agree	4. I am able to do things as well as most other people. 2	4. I am able to do things as well as most other people. 3	4. I am able to do things as well as most other people. 4	4. I am able to do things as well as most other people. 5 Strongly Disagree

	1 Strongly Agree	2	3	4	5 Strongly Disagree
5. I feel I do not have much to be proud of.	5. I feel I do not have much to be proud of. 1 Strongly Agree	5. I feel I do not have much to be proud of. 2	5. I feel I do not have much to be proud of. 3	5. I feel I do not have much to be proud of. 4	5. I feel I do not have much to be proud of. 5 Strongly Disagree

	1 Strongly Agree	2	3	4	5 Strongly Disagree
6. I certainly feel useless at times.	6. I certainly feel useless at times. 1 Strongly Agree	6. I certainly feel useless at times. 2	6. I certainly feel useless at times. 3	6. I certainly feel useless at times. 4	6. I certainly feel useless at times. 5 Strongly Disagree

	1 Strongly Agree	2	3	4	5 Strongly Disagree
7. I feel that I’m a person of worth, at least on an equal plane with others.	7. I feel that I’m a person of worth, at least on an equal plane with others. 1 Strongly Agree	7. I feel that I’m a person of worth, at least on an equal plane with others. 2	7. I feel that I’m a person of worth, at least on an equal plane with others. 3	7. I feel that I’m a person of worth, at least on an equal plane with others. 4	7. I feel that I’m a person of worth, at least on an equal plane with others. 5 Strongly Disagree

	1 Strongly Agree	2	3	4	5 Strongly Disagree
8. I wish I could have more respect for myself.	8. I wish I could have more respect for myself. 1 Strongly Agree	8. I wish I could have more respect for myself. 2	8. I wish I could have more respect for myself. 3	8. I wish I could have more respect for myself. 4	8. I wish I could have more respect for myself. 5 Strongly Disagree

	1 Strongly Agree	2	3	4	5 Strongly Disagree
9. All in all, I am inclined to feel that I am a failure	9. All in all, I am inclined to feel that I am a failure 1 Strongly Agree	9. All in all, I am inclined to feel that I am a failure 2	9. All in all, I am inclined to feel that I am a failure 3	9. All in all, I am inclined to feel that I am a failure 4	9. All in all, I am inclined to feel that I am a failure 5 Strongly Disagree

	1 Strongly Agree	2	3	4	5 Strongly Disagree
I take a positive attitude toward myself.	I take a positive attitude toward myself. 1 Strongly Agree	I take a positive attitude toward myself. 2	I take a positive attitude toward myself. 3	I take a positive attitude toward myself. 4	I take a positive attitude toward myself. 5 Strongly Disagree

And.. we're done - unless you have questions?

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Your email address *

This email will be used to provide you a copy of this assessment along with any further questions Dr. Gee may have for you prior to surgery

DISCLOSURE AGREEMENT *

I agree

You declare the information you have provided is true and correct and will be used to establish further and ongoing approval for surgery. You agree if you have not disclosed any information that is relevant to your health, physical or mental well being that your surgery may be cancelled and you will be subject to the cancellation policy as found on A New Life's Terms and Conditions. You further agree to continue to provide disclosure up to surgery if any of your medical, physical or mental health conditions change.

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Secondary Self-Assessment before bariatric surgery

Welcome to the pre-surgery secondary Self-Assessment

SECTION 1 of 20: YOUR DETAILS

SECTION 2 of 20: GENERAL CONDITIONS DISCLOSURE

SECTION 3 of 20: GENERAL MEDICAL HISTORY DISCLOSURE

SECTION 4 of 20: ANAESTHETIC HISTORY DISCLOSURE

SECTION 5 of 20: SURGICAL/PROCEDURE HISTORY DISCLOSURE

SECTION 6 of 20: CARDIOVASCULAR DISCLOSURE

SECTION 7 of 20: RESPIRATORY DISCLOSURE

SECTION 8 of 20: SLEEP APONEA DISCLOSURE

SECTION 9 of 20: LIVER/INTESTINE DISCLOSURE

SECTION 10 of 20: ENDOCRINE DISCLOSURE

SECTION 11 of 20: RENAL/KIDNEY DISCLOSURE

SECTION 12 of 20: MEDICATIONS DISCLOSURE

SECTION 13 of 20: ALLERGIES DISCLOSURE

SECTION 14 of 20: GENERAL QUESTIONS

SECTION 15 of 20: FAMILY MEDICAL HISTORY DISCLOSURE

SECTION 16 of 20: CURRENT FOOD HABITS ASSESSMENT

SECTION 17 of 20: SLEEPINESS ASSESSMENT

SECTION 18 of 20: YOUR QUALITY OF LIFE NOW

SECTION 19 of 20: YOUR ATTITUDE TOWARDS EATING

SECTION 20 of 20: SELF ESTEEM

And.. we're done - unless you have questions?

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