Weight Surgery Assessment – Before Operation

BARIATRIC PRE-SURGICAL PSYCHOLOGICAL EVALUATION

Doctor Jose Antonio Castañeda Cruz has referred the patient:

Name for an psychological evaluation.

Place and Date:

Please fill out the Bariatric Pre-Surgical Psychological Evaluation Form

The evaluation usually lasts 1 hour, depending on each patient.

Pre-surgical assessments are commonly requested for individuals who are about to undergo a bariatric surgery. Sets whether the patient suffers from personality disorders. We can see the maturity to accept surgery and sometimes guides us on family psycho environment that develop the patient's treatment.

Your assessment will be conducted by Dra. Soledad Aldana, Licensed Psychologist who will share the information with your doctor.

If necessary the doctor will be assessing personality using a wide range of tests by asking patients to answer questions and complete questionnaires.

The evaluation may provide interesting information regarding a person's personality.

Thank you for your time and effort.

If you have any questions, please call 33 15 89 90 70 and 33 15 89 80 40

Address: Av. Terranova 676-206, Colonia Providencia. Guadalajara, Jalisco. C.P. 44670

BARIATRIC PRE-SURGICAL EVALUATION FORM CONFIDENTIAL

Instructions: Please complete this form as accurately/completely as you can.

Patient's Name:

Evaluation Date:

Home Address:

Date of Birth:

Home Phone:

Work/Other Phone:

Age:

Email:

Marital Status:

Gender:

Besides referral source, do any other doctors need a copy of your report?

Which surgery are you interested in having?

INHERITED FAMILY HISTORY

Education: High school degree?

Occupation: Currently working?

Where?

Social History

How many kids do you have?

Who lives in your household? (Fill in any living at home below):

Spouse # years married:

Children #

and ages:

Parents

Other

Relationship problems:

Do you have someone who can take care of you after you are released from the hospital?

No Yes

Name:

Relation:

Weight Loss History

What is your approximate current weight?

Height?

Your Goal Weight after surgery?

How long have you been considering surgery?

What / who made you interested in the surgery?

What are your reasons for wanting the surgery?

Do you feel you adequately understand the surgical procedure?

If No, Questions:

Do you feel you adequately understand the lifestyle changes required after surgery?

If No, Questions:

How do your family / friends feel about you having the surgery?

Have you ever taken laxatives or vomited on purpose because you ate too much food?

How much and how often do you exercise?

Exercise limitations (describe):

Notes / Comments:

Medical History

Please select all that apply

Joint Pain Short of Breath High Blood Pressure High Cholesterol Sleep Apnea Arthritis Diabetes Heart Disease Asthma

Pain in:

back hips knees feet

Other (Where)

Past Surgeries:

Other medical illnesses:

Significant Symptoms

Please indicate whether you have experienced any of the symptoms below, when, and briefly describe:

Symptom:

Loss of Consciousness

No Yes

Memory Difficulties

No Yes

Blurred/Double Vision

No Yes

Muscle Jerks or Twitches

No Yes

Bowel or Bladder Problems

No Yes

Speech Difficulties

No Yes

Sleep Difficulties

No Yes

Decreased Energy

No Yes

Decreased motivation

No Yes

Decreased Happiness

No Yes

Social Isolation

Frequent Headaches

No Yes

Dizziness

No Yes

History of Anorexia

No Yes

Bulimia/vomiting/laxative

No Yes

Seizures

No Yes

Frequent Anxiety

No Yes

Persistently Depressed Mood

No Yes

Nightmares

No Yes

Angry Outbursts

No Yes

Mental Confusion

No Yes

Driving Difficulties

No Yes

Excessive Worry

No Yes

Unusual/Frightening

No Yes

Other

When it began Please briefly describe problem(s) and treatments,if any

Current Medications

Name of Medicine:

What is it for?

Please tell us about any Family History of Medical or Psychiatric Illness

Diabetes High Blood Pressure Heart problem Obesity Stroke Cancer Alcoholism Drug abuse

Other Family History of Medical or Psychiatric Illness

Family history of Psychiatric Illness

Your Psychiatric/Psychological History

Have you ever had any treatment for psychiatric/psychological difficulties (relationship counseling, psychological counseling, medicines for depression or anxiety, etc): Yes No If yes, please describe below:

Problem Date (From – To) Describe Treatment received

Have you ever considered or attempted suicide?

Describe

Have you ever heard or seen things that others didn't (hallucinations)?

Describe

Substance Use

Are you currently drinking?

Total number of years drinking on a fairly regular basis

Average amount you regularly drink (for example: 1 drink/week, 5 drinks/day, etc)

What type of alcohol do you typically drink? (12 oz. can of beer, 6 oz cup of wine, shot of hard liquor)

Have you ever been addicted to any drugs?

Describe

Have you ever failed at attempts to quit alcohol or drugs?

Describe

Have people ever said you should quit drinking or using drugs?

Describe

Have alcohol or drugs ever caused social or job problems?

Describe

Have you been involved in any treatment for drinking alcohol (including A.A.) or Using drugs?

Cigarette Smoking

Are you currently smoking?

If you smoked previously, when did you stop?

Briefly describe attempts to quit smoking:

Approximately how many years smoked in lifetime: Average number of packs/day:

INFORMED CONSENT

I agree to participate in evaluation/treatment, and the purpose has been explained to me and/or my guardian/representative.

I hereby authorize the above proffesional Soledad Aldana Aguiñaga, to obtain and release the protected information specified below.
Please list any restrictions on this release of information:

Release: This form when completed and signed by you, authorizes me to release, as well as obtain, protected information from your clinical record to and from the person(s) you designate:

Doctor Jose Antonio Castañeda Cruz

I hereby authorize Doctor Soledad Aldana Aguiñaga and/or his or her administrative and clinical staff to release any and all contents of my chart (information, psychotherapy/progress notes, test results/data, reports, visit information, prescriptions, medical information, documents provided by patient, insurance/third party forms/reports, records received by others).

Place and date:

Patient Name:

Family Name:

Date of Birth:

Signature of Patient:

Signature of family: