Bariatric/Weight-loss Surgery Evaluation
Inventory
First Name
Last Name
NAME--AUTOFILL
EMAIL--AUTOFILL
PHONE--AUTOFILL
DOB--AUTOFILL
SURGEON-CLINIC--AUTOFILL
ADDRESS--AUTOFILL
CITY--AUTOFILL
STATE--AUTOFILL
ZIP--AUTOFILL
Age
Gender
Marital Status
Occupation
Height
Feet
Inches
BMI--hidden
Weight (in lbs.)
Have you ever been diagnosed with any of the following mental health illnesses?
Other mental health illness
Have you ever been prescribed of the following mental health medications?
Other mental health medication
Have you ever had any previous weight loss surgeries?
Other weight loss surgery
Do you smoke tobacco?
PATIENT HEALTH QUESTIONNAIRE (PHQ-SADS)
PATIENT HEALTH QUESTIONNAIRE (PHQ-SADS) - This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability.
A. During the last 4 weeks, how much have you been bothered by any of the following problems?
Stomach pain
Back pain
Pain in your arms, legs, or joints (knees, hips, etc.)
Feeling tired or having little energy
Trouble falling or staying asleep, or sleeping too much
Menstrual cramps or other problems with your periods
Pain or problems during sexual intercourse
Headaches
Chest pain
Dizziness
Fainting spells
Feeling your heart pound or race
Shortness of breath
Constipation, loose bowels, or diarrhea
Nausea, gas, or indigestion
B. Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous anxiety or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
C. Questions about anxiety attacks.
In the last 4 weeks, have you had an anxiety attack; suddenly feeling fear or panic?
Has this ever happened before?
Do some of these attacks come suddenly out of the blue ? that is, in situations where you don’t expect to be nervous or uncomfortable?
Do these attacks bother you a lot or are you worried about having another attack?
During your last bad anxiety attack, did you have symptoms like shortness of breath, sweating, or your heart racing, pounding or skipping?
D. Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead of or hurting yourself in some way
E. If you checked off any problems on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
DASS-21
The DASS 21 is a 21 item self-report questionnaire designed to measure the severity of a range of symptoms common to depression, anxiety and stress. While completing the DASS, you are required to indicate the presence of a symptom over the previous week.
Please read each statement and click the circle next to how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.
I found it hard to wind down
I was aware of dryness of my mouth
I couldn't seem to experience any positive feeling at all
I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion)
I found it difficult to work up the initiative to do things
I tended to over-react to situations
I experienced trembling (e.g. in the hands)
I felt that I was using a lot of nervous energy
I was worried about situations in which I might panic and make a fool of myself
I felt that I had nothing to look forward to
I found myself getting agitated
I found it difficult to relax
I felt down-hearted and blue
I was intolerant of anything that kept me from getting on with what I was doing
I felt I was close to panic
I was unable to become enthusiastic about anything
I felt I wasn't worth much as a person
I felt that I was rather touchy
I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat)
I felt scared without any good reason
I felt that life was meaningless
Eating Attitudes Test (EAT-26)
Eating Attitudes Test (EAT-26)
Please check a response for each of the following statements:
Am terrified about being overweight.
Avoid eating when I am hungry.
Find myself preoccupied with food.
Have gone on eating binges where I feel that I may not be able to stop.
Cut my food into small pieces.
Aware of the calorie content of foods that I eat.
Particularly avoid food with a high carbohydrate content (i.e. bread, rice, potatoes, etc.)
Feel that others would prefer if I ate more.
Vomit after I have eaten.
Feel extremely guilty after eating.
Am preoccupied with a desire to be thinner.
Think about burning up calories when I exercise.
Other people think that I am too thin.
Am preoccupied with the thought of having fat on my body.
Take longer than others to eat my meals.
Avoid foods with sugar in them.
Eat diet foods.
Feel that food controls my life.
Display self-control around food.
Feel that others pressure me to eat.
Give too much time and thought to food.
Feel uncomfortable after eating sweets.
Engage in dieting behavior.
Like my stomach to be empty.
Have the impulse to vomit after meals.
Enjoy trying new rich foods.
Please respond to each of the following questions:
Have you gone on eating binges where you feel that you may not be able to stop? (Eating much more than most people would eat under the same circumstances)
How many times in the last 6 months?
Have you ever made yourself sick (vomited) to control your weight or shape?
Have you ever used laxatives, diet pills or diuretics (water pills) to control your weight or shape?
How many times in the last 6 months?
Have you ever been treated for an eating disorder?
When?
Have you recently thought of or attempted suicide?
When?
Informed Consent for Telehealth Services
Informed Consent for Telehealth Services
Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by Behavioral Health Specialists (BHS) may also include chart review, remote prescribing, prescription refills, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio-video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.
The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.BHS physicians and other healthcare professionals (our “providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.
Expected Benefits:
- Improved access to care by enabling you to remain in your home while the BHS provider consults and obtains test results at distant/other sites.
- More efficient care evaluation and management.
- Obtaining expertise of a specialist as appropriate.
Possible Risks:
- Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
- In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact BHS at (877) 583-5633.
By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:
- I hereby consent to receiving BHS’s services via telehealth technologies. I understand that BHS and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the BHS provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
- I have been given an opportunity to select a provider from BHS prior to the consult, including a review of the provider’s credentials.
- I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that BHS will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
- I understand there is a risk of technical failures during the telehealth encounter beyond the control of BHS. I agree to hold harmless BHS for delays in evaluation or for information lost due to such technical failures.
- I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the BHS providers are not able to connect me directly to any local emergency services.
- I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the BHS provider (e.g. labs or diagnostics).
- I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the BHS provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
- I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
- I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
- I will not audio or video record the telehealth consultation, although I may take still photographs to document clinical pathology.
Patient Consent
I have read this document carefully, and understand the risks and benefits of the telehealth consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.
By checking the Box containing “I CONSENT TO USING TELEHEALTH SERVICES” I hereby state that I have read, understood, and agree to the terms of this document.
Congratulations. You have completed your registration and online assessment. The next step is to register on the patient portal to schedule your interview.