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BARIATRIC
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Binge Eating Disorder Screening Tool BEDS-7
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Excessive eating episodes in the last 3 months
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Do you feel distressed about these episodes?
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How often did you feel kike you had no control over your eating
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How often did you continue eating even though you were not hungry?
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How often were you embarassed by how much you ate?
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How often did you feel disgusted with yourself or guilty afterward?
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How often did you make yourself vomit or used laxatives as a means to control your weight or shape?
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Counseling Referral
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Lap Band Adjustment
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Lap Band Adjusted
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Fluid in Band - Current
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Fluid Added
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Fluid Removed
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New Total Fluid in Lap Band
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Close to sweet spot?
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Slipped?
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Did they feel restriction from last fill?
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Radiographic studies
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Notes
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Sleep Apnea Screen
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Sleep Apnea Screening Tool
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Diagnosis of Sleep Apnea
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Last Sleep Study was
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New Short Text Field
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Uses medical device (CPAP, Bi-Pap, other)
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If yes, Current CPAP cmH2O Level:
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Does not have a formal diagnosis of sleep apnea
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Snoring
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Snoring
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choking sounds while sleeping
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choking sounds while sleeping
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Stopping breathing while sleeping
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Sleep apnea
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Fall asleep at inappropriate times
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Inappropriate falling asleep
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Most comfortable sleep position
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Most comfortable sleep
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Examiner comments
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MENTAL HEALTH
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MENTAL HEALTH
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ADHD Screen
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Attention
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Makes careless mistakes
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Poor attention
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Poor concentration
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Wrapping up
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Organizing
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Procrastinating
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Misplacing things
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Distractible
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Misses Appointments or obligations
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Total Inattention Score
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Hyperactivity
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Fidgety
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Cannot sit still for normal periods of time
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Restless
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Unwinding
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Motor
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Talking too much
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Finishes Sentences
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impatient (e.g, waiting in line for turn)
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Interrupts others
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Total Hyperactivity Score
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Depression
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Depression - PHQ-9 symptoms in the last 2 weeks
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Loss of Interest?
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Feeling down, depressed or hopeless?
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Trouble Sleeping?
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Feeling tired or having little energy?
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Poor appetite or overeating?
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Feeling bad about oneself?
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Trouble Concentrating?
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Feeling slowed down or fidgety & restless?
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Wanting to die or self harm?
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Difficulty of these problems?
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PHQ9 Scoring
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Negative Depression Screen
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Positive Depression Screen
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