Your DetailsTitle*Full Name*Date of Birth* Date Format: DD slash MM slash YYYY Referred By*Date and Type of Operation (if known)SurgeonTreating GP*Other Treating Professionals (if any)Email Address* Bariatric Surgery Psychology Questionnaire1. Have you ever had an eating disorder, either diagnosed or undiagnosed?*YesNoThis includes anorexia, bulimia, binge eating disorder or any other eating disorder.2. During the past six months, did you often eat within any two-hour period what most people would regard as an unusually large amount of food?*YesNo3. When you ate this way, did you feel out of control or that you could not stop eating?*YesNo4. During the past six months, on average, how often did you have times when you ate this way – that is, eat large amounts of food with the feeling that your eating was out of control?*Not at allLess than once a weekOnce a week2 or 3 a weekNearly every day5. Did you usually have any of the following experiences during these occasions? Eating more rapidly than usual Eating until you feel uncomfortably full Eating large amounts of food when you didn’t feel physically hungry Eating alone because you were embarrassed by your eating Feeling disgusted with yourself, depressed, or guilty after overeating 6. Do you ever wake up in the middle of the night?*YesNo6a. If and when you wake up in the middle of the night, how often do you eat at that time?*Not at allLess than once a weekOnce a week2 or 3 a weekNearly every night7. Do you eat at least a quarter of your day’s food/calories after your main evening meal?*YesNo8. Do you find that you are not hungry when you wake up in the morning?*YesNo9. Are you very distressed by this pattern of eating at night?*YesNo10. Do you currently try to control your weight by “getting rid of” what you’ve eaten in any of the following ways? Vomiting Laxatives Diuretics Diet pills Excessive exercise Other (specify below) 10a. How frequently do you use vomiting?*10a. How frequently do you use laxatives?*10a. How frequently do you use diuretics?*10a. How frequently do you use diet pills?*10a. How frequently do you use excessive exercise?*10a. What other method do you use and how frequently?*11. In the past, have you ever tried to control your weight by “getting rid of” what you’ve eaten in any of the following ways? Vomiting Laxatives Diuretics Diet pills Excessive exercise Other (specify below) 11a. How frequently did you use vomiting?*11a. How frequently did you use laxatives?*11a. How frequently did you use diuretics?*11a. How frequently did you use diet pills?*11a. How frequently did you use excessive exercise?*11a. What other method did you use and how frequently?*12. Do you find that you frequently (more than twice a week) eat in response to negative emotions?*YesNo13. Do you find that you frequently (more than twice a week) use food as a coping mechanism?*YesNo14. Do you find that you frequently use food to calm yourself?*YesNo15. Are your current emotions or stressors contributing to your weight by causing you to eat more?*YesNo16. Do you feel that eating in response to emotions contributes significantly to your weight or make it difficult to lose weight?*YesNo17. Do you find that there are times when you will eat continuously during the day or the evening rather than having set meals?*YesNo17a. If yes, when is this most likely to happen?*18. Are you currently experiencing any greater than usual stress in your life or any recent changes related to the following events? Work Health Relationship with partner / family or children Money problems Legal problems School Moving house Death / illness of an important person in your life 18a. Please explain in a sentence the above stresses you are experiencing19a. Have you ever been diagnosed with any mental health problems?*Yes - current problemYes - past problemNoneThis includes depression, anxiety, OCD, post-traumatic stress disorder, bipolar, personality disorder, autism, psychosis/schizophrenia.19b. Is your mental health currently:*StableBetter than usualWorse than usual19c. Do any mental health difficulties impact on your eating / weight?*YesNo19d. If you are currently experiencing or have previously experienced mental health problems, please provide further information.e.g. diagnosis and treatment received (medication, talking therapy, inpatient admission)19e. Have you ever engaged in deliberate self-harm?*YesNoThis includes cutting, overdoses, burning etc19f. Have you ever made a suicide attempt?*YesNo20a. How often do you have a drink containing alcohol?*Never2-4 times a month2-3 times a week4+ times a week20b. How many units of alcohol do you drink on a typical day when you are drinking?*0-23-45-67-910+1 glass of wine = 2 units, 1 pint of beer = 3 units, 1 shot of spirits = 1.5 units20c. How often have you had 6+ units of alcohol (if female) or 8+ units (if male) on a single occasion in the last year?*NeverLess than monthlyMonthlyWeeklyDaily (or almost)20d. Have you ever used cocaine, cannabis or other mind-altering drugs?*YesNo20e. Have you ever had a problem with alcohol or other drugs?*YesNo21. What do you think are the main factors contributing to your weight?*e.g. genetics, large portions, comfort-eating, health etc22. Is there anything else you would like us to know that you feel is relevant?DASS21 QuestionnairePlease read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 = Did not apply to me at all 1 = Applied to me to some degree, or some of the time 2 = Applied to me to a considerable degree, or a good part of time 3 = Applied to me very much, or most of the time1. I found it hard to wind down*01232. I was aware of dryness of my mouth*01233. I couldn't seem to experience any positive feeling at all*01234. I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)*01235. I found it difficult to work up the initiative to do things*01236. I tended to over-react to situations*01237. I experienced trembling (eg, in the hands)*01238. I felt that I was using a lot of nervous energy*01239. I was worried about situations in which I might panic and make a fool of myself*012310. I felt that I had nothing to look forward to*012311. I found myself getting agitated*012312. I found it difficult to relax*012313. I felt down-hearted and blue*012314. I was intolerant of anything that kept me from getting on with what I was doing*012315. I felt I was close to panic*012316. I was unable to become enthusiastic about anything*012317. I felt I wasn't worth much as a person*012318. I felt that I was rather touchy*012319. I was aware of the action of my heart in the absence of physical exertion*0123e.g. sense of heart rate increase, heart missing a beat20. I felt scared without any good reason*012321. I felt that life was meaningless*0123ConfidentialityPsychological service As part of providing a psychological service to you, Sea Change needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing psychological services to you. This collection of personal information will be a necessary part of the psychological assessment and treatment that is conducted. Purpose of collecting and holding information Your personal information gathered as part of your assessment and treatment is kept securely and, in the interests of your privacy, used only by your psychologist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables the psychologist to provide a relevant and informed psychological service to you. Feedback relevant to your bariatric surgery will be provided to your other treating health professionals within the Sea Change clinic, as well as your external referring party (e.g. GP or psychiatrist). A more detailed description is provided in the practice’s “Privacy policy for management of personal information”, which can be obtained by contacting the Sea Change administration team. The Privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about our management of your personal information. Disclosure of personal information All personal information gathered by the psychologist during the provision of the psychological service will remain confidential except when: 1. it is subpoenaed by a court, or disclosure is otherwise required or authorised by law; 2. failure to disclose the information would in the reasonable belief of Sea Change Clinic place you or another person at serious risk to life, health or safety; 3. your prior approval has been obtained to: (a) provide a written report to another professional or agency. e.g. a GP or a lawyer; or (b) discuss the material with another person, e.g. a parent, employer, health provider or third party funder; (c) disclose the information in another way; or (d) disclose the information to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected.Fees and Cancellation PolicyFees The cost of the initial consultation (usually around 90 minutes) is $240, which is payable at the end of the session by cash or card. The cost of subsequent sessions (usually around 50 minutes) is $160 per session, which is payable at the end of each session. Cancellation Policy If for any reason you need to cancel or postpone your appointment, you must give the psychologist at least 48 hours' notice by contacting Sea Change Clinic on (02) 4037 5858. If you fail to give such notice, you will be liable for a $50 cancellation fee, which Sea Change may deduct from your $50 deposit.SubmitAcknowledgement and Agreement* I have read and understood this Consent Form and I agree to the above terms and conditions for the psychological service provided at Sea Change Weight Loss Clinic. Please note: If, after reading this form you are at all unclear about any of the information provided, please contact the psychologist prior to your appointment.
