FARIDA BOUNOUA, M.D
Diplomat of the American Board of Surgery
Minimally Invasive and Bariatric Surgery
2323 De La Vina street suite 207
Santa Barbara, CA, 93105
Ph: 805-879-4011
Fax: 805-879-4021
Name________________________
Date:
SLEEVE GASTRECTOMY - Pre-operative Test
Please complete the following examination, answering each question carefully. Your answers will help us to be certain that you fully understand the information, which has been provided to you about your operation, and to point out to us what needs to be clarified and explained to you further.
Each statement is true or false. Please check the answer that you believe is correct:
___True ___False 1. It is important to eat high protein foods such as eggs, cheese, fish and chicken, two months
following the procedure, since malnutrition can occur.
___True ___False 2. There are no other operations or programs for obesity available, except sleeve gastrectomy.
___True ___False 3. Staple or suture lines may leak, and may result in infection, or an opening
between the stomach or intestines, and the skin
___True ___False 4. Clots may form in the legs or pelvis, which can break off and float into the
lungs. These can cause breathlessness or chest pain, and can be fatal.
___True ___False 5. It is important to exercise and to avoid snacks after the surgery.
___True ___False 6. After the surgery, patients are guaranteed to permanently lose weight.
___True ___False 7. Diabetes, high blood pressure, back pain and similar ailments always get
better after obesity surgery.
___True ___False 8. When serious complications occur, a patient may need to be in ICU for
a period of time.
___True ___False 9. Re-operation may be necessary due to bleeding, hernias, ulceration, and
a leak at one of the staple lines, blockage of the small bowel, a stitch coming
loose, or some other complication.
___True ___False 10. Sleeve gastrectomy is a cure for obesity, and afterwards patients can lead a
normal life, without regular medical care.
___True ___False 11. After obesity surgery, the patient is committed to taking vitamin and mineral
and mineral supplements, possibly including vitamin injections, for life.
___True ___False 12. If not already removed, the gallbladder may be taken out at the time of
surgery, since there is a high rate of gallbladder disease following weight loss surgery.
___True ___False 13. Obesity surgery is an easy operation, and not a very serious or risky
Procedure.
___True ___False 14. Patients don't usually feel nauseated, or vomit, after the surgery.
___True ___False 15. Complications only occur in the hospital. After discharge, medical problems
are unlikely, so it is important not to bother the doctor with minor problems.
___True ___False 16. Surgery has nothing to do with emotions, so dangerous depressions cannot
occur after obesity surgery.
___True ___False 17. Patients can be quite uncomfortable or miserable for the first 48 hours after
surgery.
___True ___False 18. After a Sleeve Gastrectomy, a person can eat as much of any kind of food as he
or she wants, and not gain weight.
___True ___False 19. In the United States, approximately one out of two hundred patients who
have obesity surgery dies.
___True ___False 20. After Sleeve Gastrectomy, there is a 1-2% risk of leak
___True ___False 21. After Sleeve Gastrectomy, significant nutritional problems with protein, iron,
vitamins, body salts or body fluids can occur.
___True ___False 22. After Sleeve Gastrectomy significant heartburn or gastric reflux may occur.
The following questions show how you learned about Gastric Bypass:
___Yes ___No I attended an informational seminar.
___Yes ___No I have reviewed information on the internet or facility Website.
___Yes ___No I have talked with other people who have had the surgery.
___Yes ___No I have received printed information about the surgery.
___Yes ___No I have had a consultation with a surgeon.
___ Yes ___ No I understand that I am to take a Anti Acid medication for a month after the surgery.
___ Yes ___ No I was given the opportunity to ask questions and was given a response to all my questions and concerns.
I certify that I took this test myself, without any help in answering the questions, during the exam.
Signature:____________________________________ Date:_____________________
Examiner:____________________________________
Incorrect answers reviewed and clarified with the patient.
______________________________________________