Bay Bariatrics Aftercare Survey #1 (Prospective)

Name(Required)

First Last

Email(Required)

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

Preparing for surgery

0-3 months after surgery

4-6 months after surgery

On a scale of 1-6, how are you feeling about having surgery?(Required)

1) Very afraid – I’m thinking about canceling my surgery

2) Somewhat afraid – I’m doubting my decision for surgery

3) Nervous – I’m having the pre-surgery jitters

4) Calm – I’m content with having surgery

5) Happy – I’m looking forward to my surgery date

6) Thrilled – I wish I could have the surgery tomorrow!

On a scale of 1-6, how supported do you feel on this journey?(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 for life after surgery?(Required)

1) Uneducated – I have no idea what to expect

2) Slightly educated- I have very little idea of what to expect

3) Somewhat educated – I have somewhat of an idea of what to expect

4) Educated – I have a general understanding of what to expect

5) More educated – I have more understanding than most of what to expect

6) Most educated – I have an advanced understanding of what to expect

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)