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Follow-up – Bariatric Surgery

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BARIATRIC SURGERY

Follow-up on your weight and state of health

Phone : 514 747-8888
extension 4411

Monday to Friday from 8 a.m. to 5 p.m.

FOLLOW-UP OF YOUR WEIGHT AND STATE OF HEALTH

1Your information

2Your surgery

3Your current condition

4End of the questionnaire

Your information*
First name Last name
Date of birth*
YYYY slash MM slash DD
Phone number where you can be reached*
Email*
Enter email Confirm email

Date of surgery (YYYY/MM)*
Type of surgery*
Weight prior to surgery (lbs)*
Lowest weight reached after surgery (lbs)*
Date (YYYY/MM)*
Your weight a year ago (lbs)*
if your surgery was in 2014 or before
Current weight (lbs)*
Considering your personal experience, what would be your desired weight? (lbs)*

How many different medications do you take on a regular basis?*
- None
- 2 and less
- 4 and less
- 6 and less
- 7 and more
Are you suffering from ... (you may select more than one)*
- High Blood Pressure
- Cardiac disease
- Diabetes
- High cholesterol
- Arthritis of the lower limbs
- I do not suffer from any of these conditions
Are you currently taking any medication for HIGH BLOOD PRESSURE?*
Are you currently taking any medication for CARDIAC DISEASE?*
Are you currently taking any medication for DIABETES?*
Are you currently taking any medication for CHOLESTEROL?*
Are you currently taking any medication for ARTHRITIS?*
How many minutes per week do you spend exercising at a light intensity level on a regular basis?*
e.g. : housework, casual walk, yoga, tai chi, etc..
- None
- 1 hour and less
- 2 hours and less
- 3 hours and less
- 4 hours and less
- More than 4 hours
For which reason(s)?*
You can choose more than one
- Lack of interest
- Lack of time
- Lack of infrastructure
- Lazyness
- Physical incapacity
How many minutes per week do you spend exercising at a moderate to high intensity level on a regular basis?*
e.g. : (brisk walk, stairs, biking, running, elliptical, etc.)
- None
- 1 hour and less
- 2 hours and less
- 3 hours and less
- 4 hours and less
- More than 4 hours
For which reason(s)?*
You can choose more than one
- Lack of interest
- Lack of time
- Lack of infrastructure
- Lazyness
- Physical incapacity
Since your surgery, have you been disciplined to follow the diet consisting of 3 meals a day with 2 snacks?*
- Always
- Regularly
- Occasionally
- Rarely
- Pratically never

Are you satisfied with your CURRENT WEIGHT?*
- I am satisfied of my current weight
- Yes, but i still have several dozens of pounds to lose
- Yes, but i still have a few dozens of pounds to lose
- Yes, but i still have a few of pounds to lose
- No, I am not satisfied of my current weight
Are you satisfied with your GENERAL STATE OF HEALTH?*
- I am satisfied of my general state of health
- Yes, but I would like to lose weight
- Yes, but I would like to get rid of my medications
- Yes, but I would like to be in better shape
- No, I am not satisfied of my general state of health
With respect to our weight loss program using Remote Patient Monitoring and telemedicine, would you like to...*
You can choose more than one
- be contacted by our coordinator to learn more about the program
- communicate with Dr. Christou to discuss about my condition and my options
I hereby understand and consent that my informations collected in this questionnaire could be used in a confidential and anonymized manner for clinical research purposes.

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To contact us

PHYSIMED MEDICAL CENTRE 6363, Transcanada Highway
Saint-Laurent (Quebec)
H4T 1Z9

Phone : 514 747-8888
Fax : 514 747-0655
Email : [email protected]

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