Assessment Form: Shiza Gull Gcuf Bs HND
Assessment Form: Shiza Gull Gcuf Bs HND
Assessment Form: Shiza Gull Gcuf Bs HND
SHIZA GULL
GCUF
BS HND
Indoor Patient Assessment Form
Last name ______________________________
First ______________________________
Birth date ______________________________
Age ______________________________
Gender Male Female
Marital status Married Single
Phone: ______________________________
Cell number: ______________________________
Email address: ______________________________
Live with: Spouse Family Friend Alone
Surgery planned: Roux-en-Y Gastric Bypass Sleeve gastrostomy
Employment: Full Time Part Time Retired Student Other
Occupation: ______________________________
Work hours: ______________________________
Medical History
Do you have a history of (please check them all)
Diabetes High Cholesterol Cancer Arthritis
High Blood Pressure Heart Disease Sleep Apnea
1 Anthropometric measurement
Height: ______________________________________
Weight ______________________________________
BMI ______________________________________
Waist circumference ______________________________________
Hip circumstance ______________________________________
WHR ______________________________________
TEE ______________________________________
Fluid requirement ______________________________________
Biochemical analysis:
CBC ______________________________________
Uric acid ______________________________________
Lipid profile ______________________________________
Blood pressure ______________________________________
Blood glucose test ______________________________________
RFT ______________________________________
Any other ______________________________________
Do you feel fatigue ever?
Little Severe No
Change in appetite:
Morning sickness/nausea/vomiting:
Yes No Sometimes
No Little Intense
Skin:
Nails:
Hairs:
Tongue:
Gums:
Eyes:
Lips:
If no, please give the reasons for not having the breakfast?
______________________________________________________________________________
Any other meal? If yes, how many times in between lunch and dinner?
______________________________________________________________________________
Amount of salt and spice you like to intake? Low Normal High
(a)Breakfast: __________________________________________________________________
(b)Lunch: __________________________________________________________________
(c)Dinner: __________________________________________________________________
Breakfast
Morning Snacks
Lunch
Evening
Dinner
Bed Snacks
Supplements if any:
Dietary Recommendations
Food Allowed Food Restricted
Carbohydrates
Proteins
Fats
Diet plan:
Prebreakfast 7 – 7:30 am
Breakfast 8 – 8:30 am
Snack 1 11:00 am
Lunch 1 – 2:00 pm
Snack 2 4:00 pm
Dinner 7 – 8:00 pm
Snack 3 10:00 pm