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Assessment forms

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I am attaching two forms. One is what I use with PCP's for medical weight loss assessment but the first group of pages can be used by and RD and has a nice graph for the patients to fill in. The second is my assessment form. Sometimes I also to a statement and reply section to assess knowledge and preparation. I give statement such as " No sugar " or " Weight regain " " Vitamin supplements for life " and ask them to say the first thing they think of in response to the statement. <<Bariatric Medical Evaluation non-wellgroup.doc>> <<initial assessment form.doc>>

Tina Musselman, R.D., C.C.N

St. Center for Bariatric Surgery

Bariatric Program Coordinator

Registered Dietitian/Certified Clinical Nutritionist

(708) 679-2717 (p)

(708) 679-2418 (f)

tina.musselman@...

www.stjameshospital.org

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