Bariatric Surgery Post-Operative Follow-up Form
Patient Information
Patient Name
Date of Birth
Medical Record Number
Follow-up Date
Vital Signs & Current Weight
Current Weight (kg)
BMI
Blood Pressure
Heart Rate
Symptoms
Nausea/Vomiting
Mild
Moderate
Severe
Absent
Pain
None
Mild
Moderate
Severe
Gastrointestinal Issues
Other Symptoms
Dietary Intake & Supplements
Diet Advancement
Clear liquids
Full liquids
Pureed foods
Soft foods
Regular bariatric diet
Daily Fluid Intake (ml)
Vitamin/Supplement Compliance
Compliant
Non-Compliant
Supplement Details
Activity & Lifestyle
Activity Level
Normal
Sedentary
Active
Moderate
Exercise Routine
Medications
Current Medications
Recent Changes to Medications
Lab & Investigation Results
Relevant Lab Results
Plan & Recommendations
Follow-up Plan & Recommendations
Clinician Information
Clinician Name
Signature