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Preop & Post Op Pt. Diet & Obesity Study:
Questions? You can talk with Dr. Rutledge Online Right Now!
Facebook: DrRRutledge, or Call on Facebook Messenger: @DrRRutledge

1. Bariatric Surgery Follow Up

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

Address 1:

City/Town:

State/Province:

ZIP/Postal Code:

Country:

Phone Number:

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* 4. Birth Date

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* 5. Age, rounded to the nearest year (NOT 85.5!)

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* 6. Email Address; May we contact you?

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* 7. Did you have the new MGB with Dr Rutledge and Dr Illan in Tijuana done with few or no staples (Also named the MGB2? )

Yes

Not Sure?

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

Height Feet:

Height Inches:

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* 9. What is your height in Centimetres? (for example 5 feet 4 inches is 162.6 cm.)

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* 10. What is you weight today in "USA POUNDS"?

Weight (lbs.) (Sorry if your wt. is in kgs, your wt in lbs is divided by 2.2 => your weight in pounds.) PS: Thanks ;-)

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* 11. What is your Weight today in Kg (Must be Whole Number between 0-500.

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

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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* 15. Have your family, friends or acquaintances had a Mini-Gastric Bypass?
MGB = Mini-Gastric Bypass

Other (please specify)

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* 16. Have you had Weight Loss Surgery?

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* 17. 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. If you did not have surgery you can leave the "After Surgery" Section blank

	0-Not at all Hungry	1-Not very hungry	2-Slight Hunger	3-Mildly Hungry	4-Average level of hunger	5-Pretty Hungry	6-Really want to eat	7-Very Hungry	8-Extremely Hungry	9-As Hungry as I can possibly imagine
Before Surgery: Average Level of Daily Hunger	Before Surgery: Average Level of Daily Hunger 0-Not at all Hungry	Before Surgery: Average Level of Daily Hunger 1-Not very hungry	Before Surgery: Average Level of Daily Hunger 2-Slight Hunger	Before Surgery: Average Level of Daily Hunger 3-Mildly Hungry	Before Surgery: Average Level of Daily Hunger 4-Average level of hunger	Before Surgery: Average Level of Daily Hunger 5-Pretty Hungry	Before Surgery: Average Level of Daily Hunger 6-Really want to eat	Before Surgery: Average Level of Daily Hunger 7-Very Hungry	Before Surgery: Average Level of Daily Hunger 8-Extremely Hungry	Before Surgery: Average Level of Daily Hunger 9-As Hungry as I can possibly imagine
After Surgery: Average Level of Daily Hunger	After Surgery: Average Level of Daily Hunger 0-Not at all Hungry	After Surgery: Average Level of Daily Hunger 1-Not very hungry	After Surgery: Average Level of Daily Hunger 2-Slight Hunger	After Surgery: Average Level of Daily Hunger 3-Mildly Hungry	After Surgery: Average Level of Daily Hunger 4-Average level of hunger	After Surgery: Average Level of Daily Hunger 5-Pretty Hungry	After Surgery: Average Level of Daily Hunger 6-Really want to eat	After Surgery: Average Level of Daily Hunger 7-Very Hungry	After Surgery: Average Level of Daily Hunger 8-Extremely Hungry	After Surgery: Average Level of Daily Hunger 9-As Hungry as I can possibly imagine

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

Other (please specify)

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* 19. If you had weight loss surgery, What was your weight on the day of surgery? USA Pounds. If "No Surgery" then What is your weight today (USA Pounds.)

Weight in USA pounds: NO Kg or Stones HERE Please

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* 20. If you had weight loss surgery, What was your weight on the day of surgery? Weight in Kgs:
If no surgery, then enter your weight in Kgs today.
NO USA pounds or Stones HERE Please

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* 21. If you have had weight loss surgery, Date of Surgery (MM/DD/YYYY) or best guess.

Op Date

Date

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* 22. If you had a bypass, How many feet were bypassed? No Bypass enter 0 (Zero)

How Many Feet Bypassed? Please enter a number between 0-20 feet (USA feet please, NOT Meters or centimeters, Please! (1 meter = approximately 3 feet., thanks)

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* 23. PreOp Weight (Double Checking your answer from above) in USA pounds only please

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* 24. Weight You Lost from Surgery. IN USA POUNDS ONLY, thanks)

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* 25. PreOp Heart Rate (If you know it, ELSE JUST ENTER A ZERO!)
If No Surgery; Enter your heart rate today.

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* 26. If You know it Enter Your Usual Resting Heart Rate Now After Surgery (If you know it, Else Enter a Zero.) (No Surgery => Leave it Blank.)

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* 27. In the 3 months before your surgery, how frequently did you exercise?
No Surgery? then enter how frequently you exercised in the last three months.

Extremely frequently

Very frequently

Moderately frequently

Slightly frequently

Not at all frequently

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* 28. In the past 3 months, how frequently did you exercise?
No Surgery? Then leave it blank.

Extremely frequently

Very frequently

Moderately frequently

Slightly frequently

Not at all frequently

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* 29. 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)
=> No Surgery? Then Enter You BM's/day in the past months.

Other (please specify)

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* 30. 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)

No Surgery? Then Skip It!

Other (please specify)

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* 31. * 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

Rarely

Often

Never

Other (please specify)

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* 32. * 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

No Surgery? Then Skip It!

Rarely

Often

Never

Other (please specify)

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* 33. Would you like help with your problems with gas, bloating, abdominal pain and bowel movements? You can talk directly with Dr Rutledge live now on Facebook Messenger Facebook Messenger: @DrRRutledge

Yes, I would like to talk with Dr. Rutledge on Facebook Messenger: @DrRRutledge

Yes, I would like to talk with Dr. Rutledge via email DrR@clos.net

Yes, I would like to talk with Dr. Rutledge in person

No Thanks

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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* 38. Did you Eat Meat * BEFORE * Surgery? (Estimate the Number of Servings per Day on Average) ESPECIALLY Processed Meat, Red 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.)

Other (please specify)

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* 39. Do you Eat Meat * Now AFTER * Surgery? (Estimate the Number of Servings per Day on Average) ESPECIALLY Processed Meat, Red 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.)

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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* 44. Junk Food: Did you eat Junk * Candy, Chips etc Before * Surgery? (Estimate the Number of Servings per Day on Average of Junk Food)

Other (please specify)

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* 45. Junk Food: Do you eat Junk * Candy, Chips Now etc After * Surgery? (Estimate the Number of Servings per Day on Average of Junk Food)

Other (please specify)

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* 46. Depression: Before Surgery Did You Suffer From Depression (Grade from 0 to 5)

0 No Depression, I Felt Great Almost All of the Time, No Depression

1 Mild, Occasionally Depressed or Feeling Down

2 Moderate, Some good Days Some Bad Days

3 Severe Taking Medications that Helped

4 Severe Taking Medications that DID NOT Help

5 Severe Taking Medications, Hospitalized for Some Period

Other (please specify)

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* 47. Depression: AFTER Surgery Did You Suffer From Depression (Grade from 0 to 5)

0 No Depression, I Felt Great Almost All of the Time, No Depression

1 Mild, Occasionally Depressed or Feeling Down

2 Moderate, Some good Days Some Bad Days

3 Severe Taking Medications that Helped

4 Severe Taking Medications that DID NOT Help

5 Severe Taking Medications, Hospitalized for Some Period

Other (please specify)

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* 48. limited Depression: AFTER Surgery. Did You have a "LIMITED" period of Depression after surgery

0 No Depression, I Felt Great Almost All of the time

1 Week of sadness, tears, feeling down or confusion

1 Month of sadness, tears, feeling down or confusion

Several Months of sadness, tears, feeling down or confusion

1 year or more of sadness, tears, feeling down or confusion

Other (please specify)

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* 49. "IF" You Did Have a Limited Period of Depression after surgery, Did your Dr Give You Estrogen?

I DID NOT have a Limited" period of depression after surgery

No Estrogen: I Did have a limited period of depression after surgery and my Dr. Did Not mention Estrogen

Estrogen-Did Well: I Did have a limited period of depression after surgery and my Dr. Did give me Estrogen

Estrogen-No Help: I Did have a limited period of depression after surgery and my Dr. Did give me Estrogen

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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

Other (please specify)

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* 54. How would you judge your weight loss following MGB?

Perfect, I lost all the weight I hoped for

Good, I lost a lot of weight, I wish I could lose more

Fair, I lost some weight

Poor, I did not lose much weight

Poor, I lost much, too much weight

Other (please specify)

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

Yes, I commonly suffer from symptoms of excess gas, abdominal bloating and distension, diarrhea, and abdominal pain.

No, I DO NOT commonly suffer from symptoms of excess gas, abdominal bloating and distension, diarrhea, and abdominal pain.

Other (please specify)

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* 56. Have You Had a Complication from weight loss surgery

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* 57. Complication Description

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* 58. Did you have one of the Top 11 Serious/Major Complications. You can contact Dr Rutledge on Facebook Messenger Right Now to talk about it:
Facebook Messenger: @DrRRutledge

Severe/Major/Persistent Acid/Bile reflux

Severe/Persistent Nausea and vomiting

Severe/Persistent Dumping syndrome, Low blood sugar

Severe/Major Gallstones or Hernia needing surgery

Severe/Major Bleeding, Blood clots, Lung or Heart problems

Severe/Major Leak, Perforation of stomach or intestines

Severe/Major Stricture, Blockage, Bowel obstruction

Severe/Major Ulcers

Severe/Major Major Weight regain or failure to lose weight

Severe/Major Vitamin or iron deficiency

Severe/Major Excessive weight loss, Malnutrition

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* 59. Please Contact Me, I want to talk with Dr Rutledge: You can talk to Dr Rutledge right now! on Facebook Messenger: @DrRRutledge or EMAIL DRR@CLOS.NET

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* 60. Do You Have a Question; What's your question, to get an answer now contact Dr Rutledge on Facebook Messenger: @DrRRutledge or Email at DrR@clos.net

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

Yes, Successful * without * Complications

Yes, Successful but * with * Complications

Yes, Unsuccessful

Other (please specify)

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* 62. Have you had pregnancy after MGB?

Yes, Successful * without * Complications

Yes, Successful but * with * Complications

Yes, Unsuccessful

Other (please specify)

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* 63. Did You Have Diabetes Before Surgery?

Yes

Other (please specify)

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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. Birth Date

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* 5. Age, rounded to the nearest year (NOT 85.5!)

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* 6. Email Address; May we contact you?

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* 7. Did you have the new MGB with Dr Rutledge and Dr Illan in Tijuana done with few or no staples (Also named the MGB2? )

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

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* 9. What is your height in Centimetres? (for example 5 feet 4 inches is 162.6 cm.)

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* 10. What is you weight today in "USA POUNDS"?

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* 11. What is your Weight today in Kg (Must be Whole Number between 0-500.

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

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

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

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* 15. Have your family, friends or acquaintances had a Mini-Gastric Bypass?MGB = Mini-Gastric Bypass

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* 16. Have you had Weight Loss Surgery?

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* 17. 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. If you did not have surgery you can leave the "After Surgery" Section blank

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

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* 19. If you had weight loss surgery, What was your weight on the day of surgery? USA Pounds. If "No Surgery" then What is your weight today (USA Pounds.)

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* 20. If you had weight loss surgery, What was your weight on the day of surgery? Weight in **Kgs**: If no surgery, then enter your weight in Kgs today. NO USA pounds or Stones HERE Please

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* 21. If you have had weight loss surgery, Date of Surgery (MM/DD/YYYY) or best guess.

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* 22. If you had a bypass, How many feet were bypassed? No Bypass enter 0 (Zero)

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* 23. PreOp Weight (Double Checking your answer from above) in USA pounds only please

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* 24. Weight You Lost from Surgery. IN USA POUNDS ONLY, thanks)

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* 25. PreOp Heart Rate (If you know it, ELSE JUST ENTER A ZERO!)If No Surgery; Enter your heart rate today.

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* 26. If You know it Enter Your Usual Resting Heart Rate Now After Surgery (If you know it, Else Enter a Zero.) (No Surgery => Leave it Blank.)

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* 27. In the 3 months before your surgery, how frequently did you exercise?No Surgery? then enter how frequently you exercised in the last three months.

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* 28. In the past 3 months, how frequently did you exercise?No Surgery? Then leave it blank.

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* 30. 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)No Surgery? Then Skip It!

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* 31. * 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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* 32. * 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-smellingNo Surgery? Then Skip It!

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* 33. Would you like help with your problems with gas, bloating, abdominal pain and bowel movements? You can talk directly with Dr Rutledge live now on Facebook Messenger Facebook Messenger: @DrRRutledge

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

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

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

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

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

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

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

* 15. Have your family, friends or acquaintances had a Mini-Gastric Bypass?
MGB = Mini-Gastric Bypass

* 20. If you had weight loss surgery, What was your weight on the day of surgery? Weight in Kgs:
If no surgery, then enter your weight in Kgs today.
NO USA pounds or Stones HERE Please

* 25. PreOp Heart Rate (If you know it, ELSE JUST ENTER A ZERO!)
If No Surgery; Enter your heart rate today.

* 27. In the 3 months before your surgery, how frequently did you exercise?
No Surgery? then enter how frequently you exercised in the last three months.

* 28. In the past 3 months, how frequently did you exercise?
No Surgery? Then leave it blank.

* 30. 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)

No Surgery? Then Skip It!

* 32. * 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

No Surgery? Then Skip It!

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

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

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

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

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

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

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

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

* 44. Junk Food: Did you eat Junk * Candy, Chips etc Before * Surgery? (Estimate the Number of Servings per Day on Average of Junk Food)

* 45. Junk Food: Do you eat Junk * Candy, Chips Now etc After * Surgery? (Estimate the Number of Servings per Day on Average of Junk Food)

* 58. Did you have one of the Top 11 Serious/Major Complications. You can contact Dr Rutledge on Facebook Messenger Right Now to talk about it:
Facebook Messenger: @DrRRutledge