Pre-Bariatric Surgery Mental Health Evaluation Simple as 1-2-3 Complete Patient Registration Complete the Assessment and Interview Evaluation Pay $150 via email invoice. PLEASE COMPLETE ALL SECTIONS IN ONE SITTING. UPON COMPLETION CLICK THE "SUBMIT" BUTTON.. Although some patients may finish sooner, we recommend allowing at least 20-40 minutes to complete. Please follow the directions at the top of the page in each section. We respect your privacy and will never disclose your personal information without your written consent. Don’t accept any help in answering questions. The answers must be solely your own. If you have any questions please call us at (806) 239-3848.First Name* Middle Name Last Name* GenderMaleFemaleAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Number To Reach You AtHomeCellWorkPhone Number*Age Marital StatusMarriedSingleSeparatedDivorcedEmploymentFull TimePart TimeUnemployedHomemakerStudentEmployer if Applicable Occupation if Applicable Date of Birth MM/DD/YYYYEmail Address* Enter Email Confirm Email Clinic/Surgeon Height Feet InchesWeight lbsApproximate Month and Day of Surgery MM/DDAre you currently or in the past, have you seen a mental health therapist?Choose oneYesNoIs this your first bariatric mental health evaluation?Please ChooseYesNoCheck To Agree* I agree to online inventories and further agree to telephone/FaceTime interviews. Wahler Physical Symptoms Inventory WHAT YOU ARE TO DO:Below is a list of physical troubles. Please indicate how often each of these bothers you. Do this by circling the number to the right of each trouble which shows how often you are bothered by that trouble. Keep in mind that the LARGER the number the MORE OFTEN the trouble bothers you. Please DO NOT SKIP any troubles. You may take as much time as is necessary. 0 = Almost Never 1 = About Once A Year 2 = About Once A Month 3 = About Once A Week 4 = About Twice A Week 5 = Nearly Every Day 1. Nausea (feeling like throwing up).* 0 1 2 3 4 5 2. Headaches.* 0 1 2 3 4 5 3. Trouble with ears or hearing.* 0 1 2 3 4 5 4. Neck aches or pains.* 0 1 2 3 4 5 5. Feeling hot or cold regardless of the weather.* 0 1 2 3 4 5 6. Arm or leg aches or pains.* 0 1 2 3 4 5 7. Shakiness.* 0 1 2 3 4 5 8. Swelling of arms, hands, legs or feet.* 0 1 2 3 4 5 9. Stuttering or stammering.* 0 1 2 3 4 5 10. Difficulty sleeping.* 0 1 2 3 4 5 11. Losing weight.* 0 1 2 3 4 5 12. Backaches.* 0 1 2 3 4 5 13. Intestinal or stomach troubles.* 0 1 2 3 4 5 14. Difficulty with urination (passing water).* 0 1 2 3 4 5 15. Heart trouble.* 0 1 2 3 4 5 16. Trouble with teeth.* 0 1 2 3 4 5 17. Numbness or lack of feeling in any part of the body.* 0 1 2 3 4 5 18. Aches or pains in hands or feet.* 0 1 2 3 4 5 19. Fainting spells.* 0 1 2 3 4 5 20. Excessive perspiration.* 0 1 2 3 4 5 21. Abnormal blood pressure.* 0 1 2 3 4 5 22. Paralysis (unable to move parts of body).* 0 1 2 3 4 5 23. Trouble with eye or vision.* 0 1 2 3 4 5 24. Burning, tingling, or crawling feelings in skin.* 0 1 2 3 4 5 25. Skin trouble(Rashes,boils or itching).* 0 1 2 3 4 5 26. Feeling tired.* 0 1 2 3 4 5 27. Muscular weakness.* 0 1 2 3 4 5 28. Dizzy spells.* 0 1 2 3 4 5 29. Muscular tensions.* 0 1 2 3 4 5 30. Any trouble with the senses of taste or smell.* 0 1 2 3 4 5 31. Difficulty breathing (short of breath, asthma, etc.).* 0 1 2 3 4 5 32. Twitching muscles.* 0 1 2 3 4 5 33. Poor health in general.* 0 1 2 3 4 5 34. Excessive gas.* 0 1 2 3 4 5 35. Difficulty swallowing.* 0 1 2 3 4 5 36. Seizures (convulsions or fits).* 0 1 2 3 4 5 37. Gaining weight.* 0 1 2 3 4 5 38. Difficulty with appetite.* 0 1 2 3 4 5 39. Bowel trouble (constipation or loose bowels).* 0 1 2 3 4 5 40. Vomiting.* 0 1 2 3 4 5 41. Chest pains.* 0 1 2 3 4 5 42. Hay fever or other allergies.* 0 1 2 3 4 5 Please indicate any important physical symptoms not listed above which troubles you: PAS™ RESPONSE FORM HS Read each statement and decide whether it is an accurate statement about you. If the statement is FALSE, NOT AT ALL TRUE, select F. If the statement is SLIGHTLY TRUE, select ST. If the statement is MAINLY TRUE, select MT. If the statement is VERY TRUE, select VT. Give your own opinion of yourself. Be sure to answer every statement by using the circle next to the corresponding answer.1. My friends are available if I need them.* F _ ST MT VT 2. I'm a very sociable person.* F _ ST MT VT 3. I'm a "take charge" type of person.* F _ ST MT VT 4. Sometimes I let little things bother me too much.* F _ ST MT VT 5. I've thought about ways to kill myself.* F _ ST MT VT 6. It's often hard for me to enjoy myself because I'm worrying about things.* F _ ST MT VT 7. Some people do things to make me look bad.* F _ ST MT VT 8. I've done some things that weren't exactly legal.* F _ ST MT VT 9. It's a struggle for me to get things done with the medical problems I have.* F _ ST MT VT 10. People around me are faithful to me.* F _ ST MT VT 11. I am in good health.* F _ ST MT VT 12. My drinking seems to cause problems in my relationship with others.* F _ ST MT VT 13. I never use illegal drugs.* F _ ST MT VT 14. Some people keep me from trying to get ahead.* F _ ST MT VT 15. I have thought about suicide for a long time.* F _ ST MT VT 16. I have a bad temper.* F _ ST MT VT 17. It takes a lot to make me angry.* F _ ST MT VT 18. I spend money too easily.* F _ ST MT VT 19. I make friends easily.* F _ ST MT VT 20. I'm almost always a happy and positive person.* F _ ST MT VT 21. I never drive when I've been drinking.* F _ ST MT VT 22. People think I'm aggressive.* F _ ST MT VT SYMPTOMS CHECKLIST Please check ANY items that are TRUE to you or an issue to you.1. SO Headaches Faintness or dizziness Pains in head or chest Pains in lower back Nausea or upset stomach Soreness of your muscles Trouble getting your breath Hot or cold spells Numbness or tingling in parts of your body Feeling weak in parts of your body 2. OC Repeated unpleasant thoughts that won't leave your mind Trouble remembering things Worried about sloppiness or carelessness Feeling blocked in getting things done Having to do things very slowly to insure correctness Having to check and double-check your actions Difficulty making decisions Your mind going blank Trouble concentrating Having to repeat the same actions such as touching, counting, washing, etc. 3. IP Feeling critical of others Feeling shy with opposite sex Feelings easily hurt Feeling others do not understand you Feeling that people are unfriendly Feeling inferior to others Feeling uneasy if people watch you Feeling self-conscious with others Feeling uncomfortable about eating in public Feeling easily embarrassed 4. D Loss of sexual interest or pleasure Feeling low in energy or slowed down Crying easily Feeling or being caught or trapped Blaming yourself for things Feeling blue Worrying too much over things Feeling no interest in things Feeling hopeless about the future Thoughts of ending your life 5. AN Nervousness or shakiness inside Trembling Suddenly scared for no reason Feeling fearful Heart pounding or racing Feeling tense or keyed up Spells of panic Feeling so restless you couldn't sit still The feeling that something bad is going to happen to you Thoughts and images of an accident 6. H Feeling easily annoyed or irritated Uncontrollable temper outbursts Having urges to beat up/injure people Having urges to break/smash things Getting into frequent arguments Shouting or throwing things Having physical fights Daydreaming about violence Fear of losing control Constant reading/watching TV of violence accounts 7. PH Feeling afraid in open spaces or in the streets Fear to go out of your house alone Fear of travel on buses,subways,or trains Having to avoid certain things, places, or activities because they frighten you Feeling uneasy in crowds,such as shopping malls or at a movie Fear of heights Fear of flying Afraid of tight places like elevators Feeling nervous when left alone Feeling afraid you will faint in public 8. PA Feeling intent on "getting even" Feeling others are to blame for most of your troubles Feeling that most people can't be trusted Feeling that you are being watched or talked about by others Having ideas or beliefs that others do not share Others not giving you proper credit for your achievements Feeling that people will take advantage of you if you let them Feeling someone is following you Feeling that people keep secrets from you Feel that bad things may happen to you 9. PS The idea that someone else can control your thoughts against your will Hearing voices that others do not hear Other people being aware of your private thoughts Think you are emotionally disturbed Think about hurting or killing yourself Having thoughts about sex that bother you a lot The idea that you should be punished for your sins Thinking that it would be fortunate to have a fatal accident The idea that something is wrong with your mind Thoughts about cutting or disfiguring yourself THANK YOU Δ
