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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your date of birth?

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* 4. An adult is a good candidate for bariatric surgery to treat morbid obesity if:

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* 5. There are three types of operations for obesity:  Making the stomach smaller, rearranging the intestines so you absorb less energy from your food, and a combination of both.

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* 6. Bariatric surgery is a TOOL.  The surgery does not replace healthy eating habits AND exercise.  It is possible to "out eat" the changes made to your stomach during weight loss surgery.

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* 7. The gastric SLEEVE involves removing 80-90% of your stomach, leaving only a banana-shaped tube.

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* 8. The gastric SLEEVE surgery:

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* 9. The banana-shaped tube of the stomach made during a gastric SLEEVE surgery causes more back-pressure from the new "sleeve pouch" into the esophagus.  The Salem Health Bariatric Surgery Program will not do a gastric SLEEVE on people with:

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* 10. The gastric SLEEVE surgery involves __________rearrangement of your internal organs than gastric BYPASS surgery.

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* 11. The gastric BYPASS surgery results in __________than the gastric SLEEVE surgery. 

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* 12. Gastric BYPASS surgery involves making a small pouch from your stomach and cutting and rerouting the small intestine.  Food then bypasses most of the stomach and upper part of your small intestine so your body absorbs fewer calories.

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* 13. People than have bariatric surgery can expect to loose 50% to 75% of their excess body weight.  Some factors that affect weight loss are:

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* 14. Some complications that are possible during and after Gastric BYPASS surgery are:

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* 15. Some complications that are possible during and after Gastric SLEEVE surgery are:

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* 16. About 2 weeks BEFORE surgery you will go on a:

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* 17. AFTER surgery you will be on a liquid diet for 2 weeks, then liquids and soft foods for the second 2 weeks and then gradually add regular foods after that.

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* 18. It is essential to follow-up with the bariatric provider and dietitian to:

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* 19. After surgery certain products can cause major problems and should be avoided.  These include all below EXCEPT:

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* 20. After surgery you will need to take certain vitamins for life including:

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* 21. Exercise is the key to maintaining long-term weight loss and health

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* 22. Dumping syndrome is a feeling of dizziness, nausea, fatigue, sweating and a large amount of diarrhea.  This can occur after Gastric BYPASS and is caused by:

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* 23. Women should not get pregnant for at least 18 months after surgery to avoid the mother and baby having problems with malnutrition and birth defects.

Patient Signature: ___________________________________________________________                                  Date: __________________________________

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