Whole Health Weight Loss Institute

POST-OP FOLLOW-UP

Post-op follow-up questionnaire.

Please complete this before your follow-up visit so Dr. Perryman can review your progress in advance.

This form is not monitored in real time. If you are having chest pain, trouble breathing, severe abdominal pain, or heavy bleeding, call 911 or go to the nearest emergency room. For urgent questions during office hours, call (707) 721-3500.

Patient

Symptoms since surgery

Have you experienced any nausea?

Have you experienced any vomiting?

Have you experienced any regurgitation?

Or reflux?

Weight & nutrition

Are you taking a daily multivitamin?

Are you taking other prescribed medication (Pantoprazole / Ursodiol)?

Exercise

Are you exercising?

Medications

Were you taking any medications before surgery?

Emergency room & hospital

Have you been to the emergency room since surgery, within 60 days of surgery?

Symptoms since last visit

Since your last visit have you experienced any symptoms? Select all that apply.

Diet sample

Signature

Prefer to print it?

You can download and print this questionnaire, fill it in by hand, and bring it to your appointment.

Download the questionnaire (PDF)Descargar en español (PDF)