1. Mini-Gastric Bypass/Bariatric Surgery & Surgery Follow Up

We are particularly interested in survey results rating your surgeon and your results of your surgery
Tell us what has happened to you since your operation us.

Email questions: DrR@clos.net
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* 1. First Name

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* 2. Last Name

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* 3. Follow Up Patient Information

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* 4. Email Address

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* 5. What is your height in Feet and Inches? (example 5 Feet 4 inches) ** USA Patients **

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* 6. What is your height in Centimeters?  ** World Patients (Metric) **

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* 7. What is you weight today in pounds?  ** USA Patients **

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* 8. What is you weight today in Kilograms?  ** World Patients (Metric) **

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* 9. Would you like to to meet with Dr. Rutledge

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* 10. Have your family, friends or acquaintances had RNY gastric bypass?
RNY = Old, "Standard" Gastric Bypass

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* 11. Have your family, friends or acquaintances had a Lap Band?

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* 12. Have your family, friends or acquaintances had a Sleeve?

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* 13. Have your family, friends or acquaintances had a Mini-Gastric Bypass?
MGB = Mini-Gastric Bypass/OAGB One Anastomosis Gastric Bypass

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* 14. Have you had Weight Loss Surgery?

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* 15. If you had weight loss surgery; Please Grade Your Overall Feelings of Hunger for an average day, with 1 being not hungry, 5 being average level of hunger and 10 being as hungry as you can imagine.

  Not at all Hungry Not very hungry Slight Hunger Mildly Hungry Average level of hunger Pretty Hungry Really want to eat Very Hungry Extremely Hungry As Hungry as I can possibly imagine
Before Surgery: Average Level of Daily Hunger
After Surgery: Average Level of Daily Hunger

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* 16. If you had an MGB/OAGB; Did you have a weight loss surgery before your MGB?

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* 17. If you had weight loss surgery, What was your weight on the day of surgery?

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* 18. If you have had weight loss surgery, Date of Surgery

Date

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* 19. If you had a bypass, How many feet/meters were bypassed?

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* 20. Year of Weight Loss Surgery (Double Checking your answer from above)

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* 21. PreOp Weight ** Lbs. or  Kgs **  (Double Checking your answer from above)

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* 22. Weight You Lost from Surgery ( Lbs.   or   Kgs. )

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* 23. PreOp BMs: Can you estimate the average number of bowel movements per day that you had prior to surgery? (you can use decimals, for example 0.5 would mean that you usually would have a bowel movement every other day, 0.25 = average 1 BM every 4 days)

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* 24. After Surgery BMs: Can you estimate the average number of bowel movements per day that you * Have Now After Surgery? * (you can use decimals, for example 0.5 would mean that you usually would have a bowel movement every other day, 0.25 = average 1 BM every 4 days)

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* 25. * Before * the MGB: Did you have Steatorrhea "excess fat in bowel movements." Stools may also float due to excess fat, have an oily appearance and be especially foul-smelling

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* 26. * AFTER * the MGB: Did you have Steatorrhea "excess fat in bowel movements." Stools may also float due to excess fat, have an oily appearance and be especially foul-smelling

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* 27. Would you like help with your problems with gas, bloating, abdominal pain and bowel movements?

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* 28. Did you Drink Sugary or "Diet" Soft Drinks (Soda Pop) or Gatorade * BEFORE * Surgery? (Estimate the Number of ** Cans you Drink per Day ** on Average.)

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* 29. Do you Drink Sugary or "Diet" Soft Drinks (Soda Pop) or Gatorade Now * AFTER * Surgery? (Estimate the Number of ** Cans you Drink per Day ** on Average.)

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* 30. Did you Eat Fried Foods * BEFORE * Surgery? (Estimate the Number of ** Servings per Day ** on Average.)

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* 31. Do you Eat Fried Foods * Now After * Surgery? (Estimate the Number of ** Servings per Day ** on Average.)

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* 32. Did you Eat Processed Meats * BEFORE * Surgery? (Estimate the Number of ** Servings per Day ** on Average) Processed Meat = hot dogs, sausages, salami, bologna, bratwurst, bacon, salt pork, cold cuts and lunch meat, ham, pastrami, pepperoni, smoked fish, corned beef, and jerky etc.)

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* 33. Do you Eat Processed Meats * Now AFTER * Surgery? (Estimate the Number of ** Servings per Day ** on Average) Processed Meat = hot dogs, sausages, salami, bologna, bratwurst, bacon, salt pork, cold cuts and lunch meat, ham, pastrami, pepperoni, smoked fish, corned beef, and jerky etc.)

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* 34. Did you eat Fresh Fruits and Vegetables * BEFORE * Surgery? (Estimate the Number of ** Servings per Day ** on Average)

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* 35. Do you eat Fresh Fruits and Vegetables * AFTER * Surgery? (Estimate the Number of ** Servings per Day ** on Average)

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* 36. Did you eat Yogurt * BEFORE * Surgery? (Estimate the Number of ** Servings per Day ** on Average)

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* 37. Do you eat Yogurt * Now After * Surgery? (Estimate the Number of ** Servings per Day ** on Average)

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* 38. PLAIN YOGURT: Do you eat Yogurt * PLAIN YOGURT Now After * Surgery? (Estimate the Number of ** Servings per Day ** on Average of PLAIN YOGURT)

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* 39. High Blood Pressure? * Before * the MGB: Did you have High Blood Pressure?

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* 40. High Blood Pressure? * AFTER * the MGB: Did you have High Blood Pressure?

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* 41. Weak & Dizzy? * Before * the MGB: Did you have Episodes of feeling "Weak and Dizzy" that was "Fixed" by eating some Salt or Salty Foods?

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* 42. Weak & Dizzy? * AFTER * the MGB: Did you have Episodes of feeling "Weak and Dizzy" that was "Fixed" by eating some Salt or Salty Foods?

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* 43. How would you judge your weight loss following MGBOAGB or other Bariatric Surgery?

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* 44. Did you have a pregnancy * BEFORE * the MGB?

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* 45. Have you had pregnancy after MGB?

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* 46. Did You Have Diabetes Before Surgery?

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* 47. Do You Have Diabetes Now After Surgery?

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* 48. Did You Take Oral Medications for Diabetes Before Surgery?

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* 49. Did You Take Insulin for Diabetes Before Surgery?

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* 50. Do You Take Oral Medications for Diabetes Now After Surgery?

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* 51. Do You Take Insulin for Diabetes Now After Surgery?

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* 52. What was you usual Glycoslylated Hemoglobin (HbA1c) BEFORE Surgery? (If you know it)

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* 53. What is you Glycoslylated Hemoglobin (HbA1c) *AFTER* Surgery? (If you know it)

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* 54. Who was your surgeon?

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* 55. Recommend your Dr. to a Friend or Family Member:
Would you recommend your Dr. to family/friends?

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* 56. Level of Trust your surgeon to make decisions/recommendations that are in your best interests?

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* 57. Helps Patients Understand Their Condition:
Does the physician help you understand your medical condition(s)?

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* 58. Listens and Answers Questions:
Does the physician listen to you and answer your questions?

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* 59. Time Spent with Patient:
Do you feel the physician spends an appropriate amount of time with you?

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* 60. Do you suffer from symptoms of excess gas, abdominal bloating and distension, diarrhea, and abdominal pain?

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* 61. Complications from weight loss surgery

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* 62. Complication Description

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* 63. Before MGB/OAGB How Satisfied Were You with Your Life. Rate Between 0-10

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* 64. After MGB/OAGB How Satisfied Are You with Your Life NOW. Rate Between 0-10

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* 65. Please Contact Me, I want to talk with Dr Rutledge

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* 66. What's your question

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