Bay Bariatrics Aftercare Survey #1 (Post-Operative)

Name(Required)

First Last

Email(Required)

Currently, where are you in your surgical journey?(Required)

0-5 months after surgery

6 months – 1 year after surgery

>1 year after surgery

How many days of the week do you take your entire bariatric vitamin regimen, correctly?(Required)

How many days of the week do you move your body intentionally?(Required)

How many days of the week do you meal prep food for yourself at home?(Required)

How alone do you feel on your bariatric journey at this specific point in time?(Required)

1) Very isolated and alone- I have a general sense of emptiness

2) Somewhat alone- I have 1 acquaintance I can talk to

3) Alone – I have a limited group of acquaintances

4) Somewhat supported – I have 1 close friend I can talk to

5) Supported – I have support from a loved one close to me

6) Thoroughly support – I have support from many loved ones close to me

On a scale of 1-6, how EDUCATED do you feel about living a bariatric lifestyle?(Required)

1) Uneducated – I have no awareness of how to apply the bariatric guidelines into my lifestyle

2) Slightly educated- I have very little idea of how to apply the bariatric guidelines into my lifestyle

3) Somewhat educated – I have somewhat of an idea of how to apply the bariatric guidelines into my lifestyle

4) Educated – I have a general understanding of how to apply the bariatric guidelines into my lifestyle

5) More educated – I have more understanding than most of how to apply the bariatric guidelines into my lifestyle

6) Most educated – I have an advanced understanding of how to apply the bariatric guidelines into my lifestyle

On a scale of 1-6, how CONFIDENT do you feel about sustaining your weight loss long-term?(Required)

1) Not confident at all

2) Slightly confident

3) Somewhat confident

4) Confident

5) More confident

6) Most confident

On a scale of 1-6, how well do you understand your RELATIONSHIP WITH FOOD and the impact food has on your body?(Required)

1) No understanding – I have no insight into my relationship with food and my eating habits

2) Slight understanding- I have very little insight into my relationship with food and my eating habits

3) Some understanding – I have some insight into my relationship with food and my eating habits

4) General understanding – I have general insight into my relationship with food and my eating habits

5) More understanding – I have a moderate level of insight into my relationship with food and my eating habits

6) Most understanding – I have an advanced insight into my relationship with food and my eating habits

What kind of support are you hoping to learn from participating in our AfterCare Program?(Required)