Weight Surgery Assessment – Before Operation
BARIATRIC PRE-SURGICAL PSYCHOLOGICAL EVALUATION
Doctor Jose Antonio Castañeda Cruz has referred the patient:
Place and Date:
Please fill out the Bariatric Pre-Surgical Psychological Evaluation Form
The evaluation usually lasts 1 hour, depending on each patient.
Pre-surgical assessments are commonly requested for individuals who are about to undergo a bariatric surgery. Sets whether the patient suffers from personality disorders. We can see the maturity to accept surgery and sometimes guides us on family psycho environment that develop the patient’s treatment.
Your assessment will be conducted by Dra. Soledad Aldana, Licensed Psychologist who will share the information with your doctor.
If necessary the doctor will be assessing personality using a wide range of tests by asking patients to answer questions and complete questionnaires.
The evaluation may provide interesting information regarding a person’s personality.
Thank you for your time and effort.
If you have any questions, please call 33 15 89 90 70 and 33 15 89 80 40
Address: Av. Terranova 676-206, Colonia Providencia. Guadalajara, Jalisco. C.P. 44670
BARIATRIC PRE-SURGICAL EVALUATION FORM CONFIDENTIAL
Instructions: Please complete this form as accurately/completely as you can.
Date of Birth:
Besides referral source, do any other doctors need a copy of your report?
Which surgery are you interested in having?
Education: High school degree?
Occupation: Currently working?
How many kids do you have?
Who lives in your household? (Fill in any living at home below):
Spouse # years married:
Do you have someone who can take care of you after you are released from the hospital?
What is your approximate current weight?
Your Goal Weight after surgery?
How long have you been considering surgery?
What / who made you interested in the surgery?
What are your reasons for wanting the surgery?
Do you feel you adequately understand the surgical procedure?
If No, Questions:
Do you feel you adequately understand the lifestyle changes required after surgery?
How do your family / friends feel about you having the surgery?
Have you ever taken laxatives or vomited on purpose because you ate too much food?
How much and how often do you exercise?
Exercise limitations (describe):
Notes / Comments:
Please select all that apply
Other medical illnesses:
Please indicate whether you have experienced any of the symptoms below, when, and briefly describe:
Loss of Consciousness
Muscle Jerks or Twitches
Bowel or Bladder Problems
History of Anorexia
Persistently Depressed Mood
When it began Please briefly describe problem(s) and treatments,if any
Name of Medicine:
What is it for?
Please tell us about any Family History of Medical or Psychiatric Illness
Other Family History of Medical or Psychiatric Illness
Family history of Psychiatric Illness
Problem Date (From – To) Describe Treatment received
Have you ever considered or attempted suicide?
Have you ever heard or seen things that others didn’t (hallucinations)?
Are you currently drinking?
Total number of years drinking on a fairly regular basis
Average amount you regularly drink (for example: 1 drink/week, 5 drinks/day, etc)
What type of alcohol do you typically drink? (12 oz. can of beer, 6 oz cup of wine, shot of hard liquor)
Have you ever been addicted to any drugs?
Have you ever failed at attempts to quit alcohol or drugs?
Have people ever said you should quit drinking or using drugs?
Have alcohol or drugs ever caused social or job problems?
Have you been involved in any treatment for drinking alcohol (including A.A.) or Using drugs?
Are you currently smoking?
If you smoked previously, when did you stop?
Briefly describe attempts to quit smoking:
Approximately how many years smoked in lifetime: Average number of packs/day:
I agree to participate in evaluation/treatment, and the purpose has been explained to me and/or my guardian/representative.
I hereby authorize the above proffesional Soledad Aldana Aguiñaga, to obtain and release the protected information specified below. Please list any restrictions on this release of information:
Release: This form when completed and signed by you, authorizes me to release, as well as obtain, protected information from your clinical record to and from the person(s) you designate:
Doctor Jose Antonio Castañeda Cruz
I hereby authorize Doctor Soledad Aldana Aguiñaga and/or his or her administrative and clinical staff to release any and all contents of my chart (information, psychotherapy/progress notes, test results/data, reports, visit information, prescriptions, medical information, documents provided by patient, insurance/third party forms/reports, records received by others).
Place and date:
Date of Birth:
Signature of Patient:
Signature of family:
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