Bay Bariatrics Office Intake Survey

Name

First Last

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

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

ALL PATIENTS: 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

ALL PATIENTS: On a scale of 1-6, how supported do you feel on your health & wellness 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

ALL PATIENTS: 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

ALL PATIENTS: Which obesity management medication(s) are you currently taking?(Required)

None

GLP-1 (injectable or pill)

Phentermine

Topiramate

Metformin

Bupropion

Naltrexone

Qsymia (phentermine/topiramate)

Contrave (naltrexone/bupropion)

Choose all that apply.

SURGERY PATIENTS: On a scale of 1-6, how are you feeling about having surgery?

If you have already had surgery, you can skip this question.

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

SURGERY PATIENTS: Currently, where are you in your surgical journey?

Leading up to surgery

0-5 months after surgery

6 months – 1 year after surgery

>1 year after surgery

If you are not a metabolic surgery patient, you can skip this surgical question.

SURGERY PATIENTS: On a scale of 1-6, how EDUCATED do you feel about living a bariatric lifestyle?

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

If you are not a metabolic surgery patient, you can skip this question

SURGERY PATIENTS: How many days of the week do you take your entire bariatric vitamin regimen, correctly?

N/a – I’m pre-surgery or within a few weeks out from surgery

No days

1 day

2 days

3 days

4 days

5 days

6 days

7 days

This includes taking a bariatric multivitamin with iron and calcium citrate multiple times throughout the day. If you are not a metabolic surgery patient, you can skip this surgical question.