NAVAL HOSPITAL BEAUFORT
GASTRIC BYPASS (BARIATRICS) SCREENING QUESTIONNAIRE
NAME DATE
HOME ADDRESS
CITY STATE ZIP CODE
HOME PHONE # WORK PHONE #
AGE/DATE OF BIRTH SEX MARITAL STATUS
ID# (e.g. 20130 SPONSOR'S SS#)
SERVICE (USN, USA, USAF, USCG) STATUS (AD, RET, FAM MBR)
CURRENT PAIN LEVEL (0-10 SCALE): /10 LOCATION OF PAIN:
HOW LONG HAS WEIGHT BEEN A PROBLEM?
AS AN ADULT, THE MOST I HAVE WEIGHEDTHE LEASTCURRENT WT.
MY WEIGHT GOALI HAVE BEEN TO MY NUTRITION SCREENING APPT: YES NO
WHY I WANT TO HAVE GASTRIC BYPASS SURGERY:
DIETS TRIED
EXERCISE: CURRENT
PAST
AFTER SURGERY PLANS
ATTENDED GASTRIC BYPASS SUPPORT GROUP: YESNO PLAN TO ATTEND
PLEASE DESCRIBE ANY CURRENT MEDICAL PROBLEMS:
LIST MEDICATIONS BEING TAKEN AND REASON:
HOW DO OTHERS RESPOND TO YOUR WEIGHT PROBLEMS?
WHAT IMPACT HAS THIS PROBLEM HAD ON YOUR LIFE?
HOW WELL DO YOU SLEEP?
HOW IS YOUR APPETITE?
HOW WOULD YOU DESCRIBE YOUR MOOD?
HAVE YOU EVER SEEN A PSYCHIATRIST, PSYCHOLOGIST, CHAPLAIN, SOCIAL WORKER, OR COUNSELOR? YES NO IF YES, DATES
FOR WHAT?
ARE YOU CURRENTLY IN THERAPY?
HAVE YOU EVER FELT DEPRESSED? YES NO
IF YES, WHEN?
HAVE YOU EVER THOUGHT ABOUT ENDING YOUR LIFE? YES NO
IF YES, WHEN?
HAVE YOU EVER THOUGHT ABOUT HURTING OR KILLING ANOTHER PERSON? YES NO
IF YES, WHEN?
PERSONAL AND FAMILY HISTORY
PLACE OF BIRTH: WHERE DID YOU GROW UP?
FATHER'S AGE: HEALTH: (IF DECEASED, GIVE CAUSE AND AGEAT THAT TIME):
MOTHER'S AGE: HEALTH: (IF DECEASED, GIVE CAUSE AND AGEAT THAT
TIME):
WERE YOUR PARENTS SEPARATED OR DIVORCED? DEPRESSED? YES NO
IF YES, HOW OLD WERE YOU WHEN THAT HAPPENED?
BIRTH ORDER: HOW MANY SIBLINGS DO YOU HAVE? BROTHERS SISTERS
GIVE YOUR IMPRESSION OF THE ATMOSPHERE OF THE HOME YOU GREW UP IN:
PLEASE DESCRIBE ANY SIGNIFICANT MEDICAL, PSYCHOLOGICAL, OR SUBSTANCE ABUSE PROBLEMS SUFFERED BY ANY MEMBER OF YOUR FAMILY:
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WERE YOU EVER ABUSED:
PHYSICALLY? SEXUALLY? EMOTIONALLY?
EDUCATION:
WHAT IS THE HIGHEST GRADE/DEGREE YOU COMPLETED?
WORK HISTORY:
CURRENT JOB ASSIGNMENT:
CURRENT EMPLOYMENT STATUS: FULL TIME;PART TIME;UNEMPLOYED
LIMDU;WORKMANS COMP;SIQ
IS YOUR CURRENT JOB SITUATION STRESSFUL?
MARITAL STATUS: MARRIED? YES NO HOW LONG? IF DIVORCED, WHEN?
DESCRIBE YOUR RELATIONSHIP WITH SPOUSE:
AGES OF CHILDREN: SONS:DAUGHTERS:
STEPSONS: STEPDAUGHTERS:
WHERE DO YOUR CHILDREN RESIDE?
DESCRIBE YOUR RELATIONSHIP WITH THEM:
LEGAL/SUBSTANCE USE HISTORY
HAVE YOU EVER BEEN ARRESTED AS A JUVENILE OR ADULT?YESNO
ANY OF THE ABOVE ALCOHOL OR DRUG RELATED?YES NO
DESCRIBE YOUR CURRENT ALCOHOL USE (rare, occasional, moderate, heavy)
ALCOHOL CONSUMPTION (ie, per week, per month, or per year):
HAVE YOU EVER HAD BLACKOUTS, WITHDRAWAL, OR SHAKES FROM ALCOHOL?
HAVE YOU EVER USED ILLEGAL DRUGS?IF SO, WHEN?
NICOTINE USE (packs/day):FOR HOW LONG?
CAFFEINE CONSUMPTION:CARBONATED BEVERAGE CONSUMPTION:
PLEASE DESCRIBE ANY SIGNIFICANT CHANGES OR EVENTS WHICH HAVE OCCURRED FOR YOU IN
THE PAST 2 YEARS. WERE THESE POSITIVE OR NEGATIVE? WHEN DID THEY OCCUR?
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