Ellis Medicine Bariatric Care Center Pre-Operative Nutrition Assessment Name_ ___ Date 12/13/13 Date of Birth___ Time

In: _2:30 Time Out: _2:55 Surgery: ___ Bypass ___ ___ Slee e !ap Ban" Surgeon: ___Dr# $lar%e ___Dr# &ai _ _'_ Dr# In(ram

Family/Friend Present: ___none _____ Pre erred !anguage: ____ )n(lish ____ Spanish ____ Other: Assessment:_&t is a "iagnosis: *or+i" O+esity ,/T e'-essi e inta%e an" "e-rease" a-ti ity .)B B*I of _ __ #ntervention: &t to atten" post op nutrition -lass prior to sur(ery to "is-uss his/her nutritional nee"s after sur(ery# In"i i"ual follo/0up en-oura(e" as ne-essary# Support (roup atten"an-e /as en-oura(e"# Monitoring/Evaluation: *onitor pt1s /ei(hts2 eatin( an" e'er-ise ha+its per pt re-all after sur(ery# Nutrition -learan-e for sur(ery3 ____'___ 4es _________No Dietitian: _____________________________________________________ Tara 5oy-e2 ,D2 $DN

Ellis Medicine Bariatric Care Center Pre-Operative Nutrition Assessment Name_ ___ Date 12/13/13 6ei(ht _ _7eet_ _in-hes 7oo" .ller(ies: _N97._ Date of Birth___ 8ei(ht __ l+s#

B*I______

Diseases or 6ealth $on"itions: *or+i" o+esity2 *e"i-ations:_&lease see me"i-al re-or"_ :itamin2 *ineral2 6er+al or Other Dietary Supplements: none 1# $an you (i e me a summary of /ei(ht history: 2# 8hat %in" of "iets ha e you trie" +efore3 3# 6a e you e er trie" any o er0the -ounter or pres-ription /ei(ht loss me"i-ations3 4es No 8hi-h ones3 ;# 8hat "o you thin% has lea" to the most /ei(ht (ain3 5# 8hat -an you remem+er as your lo/est a"ult /ei(ht3 _< .t /hat a(e3 __ =# 8hat -an you remem+er as your hi(hest a"ult /ei(ht3_< .t /hat a(e3 _ ># 8hat "o you thin% losin( /ei(ht /ill "o for you3 ?# Do you ha e a (oal /ei(ht or si@e for after sur(ery3 __ A# Do you ha e any tri((er foo"s2 a -ertain time of "ay or foo"s /here that are "iffi-ult to stop eatin(3

10# 8hat re(ular physi-al a-ti ities "o you parti-ipate in at this time3

11# 8hat thin(s "o you thin% mi(ht ma%e it "iffi-ult to ma%e lifestyle -han(es3

Ellis Medicine Bariatric Care Center Pre-Operative Nutrition Assessment Name_ ___ Date 12/13/13 Date of Birth___ 12# On a s-ale of 00102 /hat is your (eneral le el of stress3 ____0____1____2____3____;____5____=____>____?____A____10 :ery ,ela'e" *ana(in( O%ay :ery Stresse" 13# 8ho else "o you li e /ith at home3 ____!i e alone ___ 6us+an"/8ife

____ 7ian-B ____Boyfrien"/Cirlfrien" ____$hil"ren i# 6o/ *any3 ____ ____&arents Other:_ _ ____ 1;# Do you an" your family eat to(ether re(ularly3 4es No

15# .re your frien"s an" family supporti e of your "e-isions to ha e /ei(ht loss sur(ery3 4es No Some

Ellis Medicine Bariatric Care Center Pre-Operative Nutrition Assessment Name_ ___ Date 12/13/13 Date of Birth___ 8oul" you say you D$he-% all that applyE: ____ Often eat on the run ___ Often eat /hen you are not really hun(ry __ __ Often sna-% /hile /at-hin( T: or usin( the -omputer __ __ Often s%ip meals ____ .l/ays eat +rea%fast ____ Sometimes eat +rea%fast __ __ ,arely eat +rea%fast ____ $ra e foo"s hi(h in su(ar ____ $ra e frie" foo"s ____ $ra e foo"s hi(h in salt ____ Drin% a lot of /ater ____ )at ery Fui-%ly ___ )at fruit an" e(eta+les e ery"ay __ __ Sna-% late at ni(ht ____ Drin% -ar+onate" +e era(es e ery"ay a# If so2 /hat %in"3__

1=# 6o/ /oul" you rate your %no/le"(e of nutrition an" healthy eatin(3

Ellis Medicine Bariatric Care Center Pre-Operative Nutrition Assessment Name_ ___ Date 12/13/13 Date of Birth___ ____0____1____2____3____;____5____=____>____?____A____10 No 9no/le"(e Some 8or%in( 9no/le"(e :ery 9no/le"(ea+le 1># 6o/ important is it for you to ma%e lifestyle -han(es3 Die# a"Gustin( your "iet2 eatin( less2 mo in( more2 et-#E ____0____1____2____3____;____5____=____>____?____A____10 Not Important Some/hat Important :ery Important 1?# 6o/ rea"y are you ri(ht no/ to ma%e lifestyle -han(es3 ____0____1____2____3____;____5____=_ _>____?____A___10 Not ,ea"y Some/hat ,ea"y :ery ,ea"y

1A# 6o/ -onfi"ent are you that you -an ma%e lifestyle -han(es an" lose /ei(ht after sur(ery3 ____0____1____2____3____;____5____=____>____?____A____10 Not $onfi"ent Some/hat $onfi"ent :ery $onfi"ent

!ean $ %reen Pop &ui'( )# Applica*le+ 1# 6o/ many oun-es of protein "o you ha e per lean H (reen meal3 2# 6o/ many (reen options "o you ha e per lean H (reen meal3 3# 8hat are some e'amples of healthy fats that are allo/e" on the lean H (reen meal plan3 ;# 6o/ many oun-es of /ater shoul" you -onsume per "ay on the lean H (reen meal plan3 5# Do you feel li%e you ha e a (oo" un"erstan"in( of the lean H (reen meal plan3