U.S. BARIATRIC POSTOPERATIVE PATIENT

ALCOHOL USE SURVEY

Name: Current Age:   Current Weight:                                  

Gender:   Male Female Surgery Date:   Preoperative Weight:  

Type of surgery:   Gastric Bypass Adjustable Gastric Band Duodenal Switch Biliopancreatic Diversion Gastroplasty

1. Did you drink alcohol before surgery?   Yes No

If Yes, approximately how much do you drink each week?   1-2 drinks 3-5 drinks 6-10 drinks > 10 drinks

(a drink is defined as 12 oz of beer, 5 oz of wine or 1.5 oz of 80 proof alcohol)

2. Do you drink alcohol now?   Yes No

If Yes, approximately how much do you drink each week?   1-2 drinks 3-5 drinks 6-10 drinks > 10 drinks

(a drink is defined as 12 oz of beer, 5 oz of wine or 1.5 oz of 80 proof alcohol)

3. Since having surgery, are you more sensitivity to the effects of alcohol?   Yes No

4. How much alcohol does it take for you to feel the effects of the alcohol?   a few sips 1 drink 2 drinks 3 drinks or more

5. After having a drink, do the effects of alcohol last for:   a longer period of time than before surgery less time than before surgery the same length of time

6. Have you ever had an occasion that drinking caused you to lose muscular control?   Yes No

If yes, how much alcohol had you consumed?   1-2 drinks 3-4 drinks 5-6 drinks > 6 drinks  

If yes, how long was your coordination impaired after you stopped drinking?  30 minutes 1 hour 2 hours > 2 hours

7. Have you received a DUI since your surgery?    Yes No

If yes, how long after surgery did you receive the DUI?  1-6 months 6-12 months 1-2 years > 1 year

If yes, how many drinks had you consumed before receiving your DUI?   1 drink 2 drinks 3-4 drinks > 5 drinks

If yes, were you were administered a breath test?    Yes No

If yes, were you administered a blood test?    Yes No

If yes, how long after drinking did you have the blood test?    Yes No