Paul Carter, M.D. | Obesity Surgery Information Assessment Tool

101 Robeson Street, Suite 200 Fayetteville, NC 28301 P: (910) 323-2696 F: (910) 323-8636

Obesity Surgery Information Assessment Tool

DIRECTIONS:
The following questions are intended to find out what you already know about the surgery for obesity. Please understand that these questions are not intended to provide you with new information about the surgery. After you have completed this handout our staff will spend personal time with you answering any questions you may have and provide detailed information about the surgery and our clinical program.

For each of the following questions, please choose the best answer. If you do not know the answer, select an answer that is your best guess.

Name:
Date:

1. After, surgery, how many ounces of food can you eat at one time?

2. How much weight can you expect to have lost one year after surgery?

3. Can any person who is overweight have obesity surgery?

4. Are there any risks or dangers with obesity surgery?

5. How much risk would you say there is?

6. Must you continue to see a doctor regularly after the surgery?

7. After losing a sufficient amount of weight, would you be required to have surgery again to "undo" the obesity surgery procedure?

8. Approximately how long does the obesity surgery take?

9. Approximately how long would you expect to stay in the hospital after obesity surgery?

10. Is it possible to gain weight following obesity surgery? Can you learn to "out eat" the effects of the surgery?

11. Will you have to change your lifestyle (exercise and eating habits) following surgery?

12. At what age did you develop a weight problem?

13. What is the most you have ever weighed?

14. How much weight do you think you should lose? pounds

15. How does you weight influence your life style?

Your health?

16. What have you tried in the past to lose weight?

PROGRAM	DATE/YEAR	WT.	AMOUNT LOST	AMT OF TIME SPENT ON EACH ATTEMPT
A. Weight Watchers
B. Diet Center
C. Nutri-System
D. Physician's Weight Loss
E. Medical Weight Loss System
F. TOPS
G. Dietician Counseling
H. Physician Monitored Diet
I. Fad Diets
J. Diet Pills
K. Low Calorie Diets
L. Liquid Diets
M. Hypnosis
N. Optifast
O. Jaw Wiring
P. Acupuncture
Q. Other

17. Do you suffer from depression? If so, how do you think the surgery and its resulting weight loss would affect your depression?

18. Have you ever had problems with the clots in your legs (deep vein thrombosis) or a clot to your lungs (pulmonary embolus)?

19. Do you have a history of stomach problems?
   Ulcers
   "Finicky" stomach
   Frequent nausea/vomiting
   Unexplained stomach pain
   Hernias
   Other

About Bariatric Surgery

Who Qualifies?

Obesity Assessment Tool