To stop all anti-depressants All of the above Including physical activity in daily routine before surgery is associated with greater weight loss and fewer complications after surgery. True False Once the surgery is performed, you do not have to do anything else. The weight loss will just happen, without regular medical care. True False Please sign to verify that all the information you have provided is accurate and to the best of your knowledge. Signature: _______________________________________________Date___/___/___ Please read and sign the following authorization: By my signature below I am authorizing ThedaCare and ThedaCare Regional Medical Bariatric Coordinator, and/or their designees to request medical information from the physicians I listed as part of this health history questionnaire on page 6. The purpose for their request of this information is so that they may coordinate my care as I pursue and investigate bariatric surgery and/or care alternatives. The types of information that they may request includes, but is not limited to: history and physical exams, discharge summaries, consultation reports, laboratory and imaging studies, clinic visits, and nutrition records. Signature: _________________________________________Date___/___/___ Please print your name:_________________________________________ Updated 4/2018
To stop all anti-depressants All of the above Including physical activity in daily routine before surgery is associated with greater weight loss and fewer complications after surgery. True False Once the surgery is performed, you do not have to do anything else. The weight loss will just happen, without regular medical care. True False Please sign to verify that all the information you have provided is accurate and to the best of your knowledge. Signature: _______________________________________________Date___/___/___ Please read and sign the following authorization: By my signature below I am authorizing ThedaCare and ThedaCare Regional Medical Bariatric Coordinator, and/or their designees to request medical information from the physicians I listed as part of this health history questionnaire on page 6. The purpose for their request of this information is so that they may coordinate my care as I pursue and investigate bariatric surgery and/or care alternatives. The types of information that they may request includes, but is not limited to: history and physical exams, discharge summaries, consultation reports, laboratory and imaging studies, clinic visits, and nutrition records. Signature: _________________________________________Date___/___/___ Please print your name:_________________________________________ Updated 4/2018
questionnaire%20survey18.docx