Duke Center for Metabolic and Weight Loss Surgery Pre-op Nutrition Questionnaire

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1 Duke Center for Metabolic and Weight Loss Surgery Pre-op Nutrition Questionnaire Name Date How long have you been considering weight loss surgery? Which procedure are you interested in having? Gastric bypass; Adjustable gastric band; Sleeve gastrectomy; Biliopancreatic Diversion with Duodenal Switch; Revision Vitamins, Minerals, Over the Counter Supplements Please list all vitamin, mineral, and over the counter supplements you take. Daily Activity / Exercise Do you currently exercise? Yes No If no, Why? If Yes, What do you do? Exercise Days/Week Time Spent Weight History: What is your current weight? LBS What is your desired goal weight? LBS What has been your highest adult weight? LBS When did your weight problem begin? Childhood Adolescent Teenager 10 years ago 15 years ago 20 years ago 30 years ago throughout life Other What do you think is the reason(s) for your weight gain? injury pregnancy overeating poor eating habits heredity lack of exercise marriage smoking cessation stress divorce other When dieting in the past, on average, how many pounds did you lose? What makes a diet successful for you?

2 From the list below what triggers you to eat: availability of food depression loneliness boredom habit hunger lack of appetite awareness self reward external cues comfort stress PMS social situations anxiety sadness cooking anger other Meal Patterns: Do you plan your meals? Who does the grocery shopping for your home? How many meals per day do you eat? How many snacks per day do you eat? Do you skip or miss meals? Yes No If Yes, what meal/s do you skip or miss How often do you miss this meal (days per week) day/s How often do eat out or pick up food from a restaurant/fast food/ cafeteria/ etc (please indicate the number of times per week) Breakfast: Lunch: Dinner: What beverages do you drink (please mark how many ounces you drink of each daily) Water Whole milk Diet soda 2% milk Regular soda Skim or 1% milk Regular coffee Juice Decaf coffee Sports Drink Sugar Free Drinks Tea regular decaf sweet unsweet Do you drink alcohol? Yes No If Yes, what type and How often Do you smoke? Yes No How would you describe your eating habits? Skip meals frequently Feeling disgusted or guilty after Eating small amounts frequently (grazing) overeating Rapid eating Eating large amounts of food Eating until uncomfortably full throughout the day Eating alone out or embarrassment Middle of the night eating Eating in front of the TV/computer/while driving

3 Please record when, what, how much, and how long you eat in a typical day. TIME FOOD ITEM AMOUNT PREP HOW LONG Breakfast A.M. Snack Lunch P.M. Snack Dinner Evening Snack Fluid Water oz Tea oz Crystal Light oz Regular Soda oz Decaf Diet Soda oz Decaf Sports Drink oz Sugar free drinks oz Regular Coffee oz Decaf Coffee oz Other Drinks oz

4 I eat BEEF Regular ground beef Lean ground beef Roast (sirloin, round, chuck) Steak Prime grades Corned beef PORK Tenderloin Loin roast Spareribs Bacon/Sausage POULTRY Chicken with skin Chicken without skin Turkey VEAL Chops Roast Breast LAMB Roast Rib Breast Commercial ground FISH Fresh/Frozen Pre-breaded, pre-fried Canned in oil Canned in water Shellfish PROCESSED MEAT Regular cold cuts Low fat cold cuts Regular hot dogs Low fat hot dogs BREAD/STARCH Cold cereal Granola cereal FOOD FREQUENCY QUESTIONNAIRE Seldom Sometimes Often Never (once or (2-4 times (5-7 times less per per week) per week) week) Frequent (more than once/day)

5 Plain hot cereal Pasta, white Pasta, wheat Rice, white Rice, brown Bread, white Bread, whole wheat Bagel Commercial biscuits, muffins, waffles, pancakes Pretzels Crackers Popcorn FRUIT/VEGETABLES Fresh fruit Canned fruit, regular Canned fruit, light Dried fruit Fruit juice Vegetable juice Fresh vegetables Frozen vegetables, plain Frozen vegetables with sauce Canned vegetables Potatoes Fried potatoes Corn/Peas Vegetable Soup DAIRY Whole milk 2% milk 1% or skim milk Soy milk Cheese, regular Cheese, low fat Yogurt Yogurt, light Cream Nondairy creamer Cream soup FATS Butter Margarine

6 Vegetables oil Mayonnaise, regular Mayonnaise, low fat Salad dressing, regular Salad dressing, low fat Sour cream, regular Sour cream, low fat Cream cheese, regular Cream cheese, low fat Gravy Nuts/Seeds OTHER Frozen entrees, regular Frozen entrees, low fat Pizza Eggs Beans/Lentils Peanut butter Tofu/Soy SNACKS Chocolate Pie/Cake Cookies, regular Cookies, low fat Hard candy Chewing gum Ice cream, regular Ice cream, low fat Frozen yogurt Pudding Chips Nabs BEVERAGES Water Sugar free drinks Regular coffee/tea Decaf coffee/tea Sweet tea Unsweet tea Regular soda Diet soda Beer Wine Liquor Sports drink

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