Bariatric Surgery Follow-Up Assessment Form
Patient Information
Patient Name
Date of Birth
Medical Record Number
Date of Visit
Surgery Type
Date of Surgery
Anthropometrics
Weight (kg)
Height (cm)
BMI
Excess Weight Loss (%)
Comorbidities Improvement
Nutrition & Lifestyle Assessment
Dietary Intake
Physical Activity
Vitamin/Mineral Supplements
Adherence to Recommendations
Clinical Assessment
Current Symptoms/Complications
Laboratory Results
Medications
Plan & Recommendations