Bariatric Surgery Post-Op Monitoring Form
Patient Information
Patient Name
Patient ID
Date of Birth
Date of Surgery
Surgery Type
Gastric Bypass
Sleeve Gastrectomy
Gastric Band
Other
Vitals and Anthropometrics
Date of Visit
Weight (kg)
BMI
Blood Pressure
Pulse
Temperature
Symptoms / Complications
Nausea/Vomiting
No
Yes
Abdominal Pain
No
Yes
Diarrhea
No
Yes
Constipation
No
Yes
Other Symptoms / Notes
Dietary Intake
Current Diet Stage
Liquid
Pureed
Soft
Regular
Protein Intake (g/day)
Fluids Intake (ml/day)
Lab Results
Hemoglobin
Vitamin B12
Ferritin
Vitamin D
Albumin
Calcium
Other Lab Notes
Medications & Supplements
Current Medications
Supplements
Follow-up Plan
Next Appointment
Additional Comments / Recommendations