Postoperative Weight Gain Survey

Please answer the following questions. All answers will remain confidential. Please do not sign your name to this paper.

  1. Did you receive the Roux-en-Y bariatric surgery?

 

  1. Has it been 24 months since your surgery?

 

  1. What was your weight the day of surgery?

 

  1. What was your weight at 24 months after surgery?

Please print out the questionnaire, complete it and mail it to Phillip Moser, 2845 Kent Rd., Silver Lake Ohio, 44224. If you are interested in the results of this study you may contact Phillip Moser, RN at (330-592-5622). Thank you for your participation.

 The Body Uneasiness Test, BUT- A

Mark with an X the answer which best expresses your experience at the moment

 

Never

Seldom

Sometimes

Often

Very Often

Always
  1. I spend a lot of time in front of the mirror

 

 

 

 

 

 

 

 

 

 

 
  1. I don’t trust my appearance: I’m afraid it will change suddenly

 

 

 

 

 

 

 

 

 

 

 

 
  1. I like those clothes which hide my body

 

 

 

 

 

 

 

 

 

 

 

 
  1. I spend a lot of time thinking about some defects of my physical appearance

 

 

 

 

 

 

 

 

 

 

 

 
  1. When I undress, I avoid looking at myself

 

 

 

 

 

 

 

 

 

 

 

 
  1. I think my life would change significantly if I could correct some of my aesthetic defects

 

 

 

 

 

 

 

 

 

 

 

 
  1. Eating with others causes me anxiety

 

 

 

 

 

 

 

 

 

 

 

 
  1. The thought of some defects of my body torments me so much that it prevents me from being with others

 

 

 

 

 

 

 

 

 

 

 

 
  1. I’m terrified of putting on weight

 

 

 

 

 

 

 

 

 

 

 

 
  1. I make detailed comparisons between my appearance and that of others

 

 

 

 

 

 

 

 

 

 

 

 
  1. If I begin to look at myself, I find it difficult to stop

 

 

 

 

 

 

 

 

 

 

 

 
  1. I would do anything to change some parts of my body

 

 

 

 

 

 

 

 

 

 

 

 
  1. I stay at home and avoid others seeing me

 

 

 

 

 

 

 

 

 

 

 

 
  1. I am ashamed of the physical needs of my body

 

 

 

 

 

 

 

 

 

 

 

 
  1. I feel I am laughed at because of my appearance

 

 

 

 

 

 

 

 

 

 

 

 

 

Never

Seldom

Sometimes

Often

Very Often

Always
  1. The thought of some defects of my body torments me so much that it prevents me studying or working

 

 

 

 

 

 

 

 

 

 

 

 
  1. I look in the mirror for an image of myself which satisfies me and I continue to search until I am sure I have found it

 

 

 

 

 

 

 

 

 

 

 

 
  1. I feel I am fatter than others tell me

 

 

 

 

 

 

 

 

 

 

 

 
  1. I avoid mirrors

 

 

 

 

 

 

 

 

 

 

 

 
  1. I have the impression that my image is always different

 

 

 

 

 

 

 

 

 

 

 

 
  1. I would like to have a thin and bony

 

 

 

 

 

 

 

 

 

 

 

 
  1. I am dissatisfied with my appearance

 

 

 

 

 

 

 

 

 

 

 

 
  1. My physical appearance is disappointing compared to my ideal image

 

 

 

 

 

 

 

 

 

 

 

 
  1. I would undergo plastic surgery

 

 

 

 

 

 

 

 

 

 

 

 
  1. I can’t stand the idea of living with the appearance I have

 

 

 

 

 

 

 

 

 

 

 

 
  1. I look at myself in the mirror and have a sensation of uneasiness and strangeness

 

 

 

 

 

 

 

 

 

 

 

 
  1. I am afraid that my body will change against my will, in a way I don’t like

 

 

 

 

 

 

 

 

 

 

 

 
  1. I feel detached from my body

 

 

 

 

 

 

 

 

 

 

 

 
  1. I have the sensation that my body does not belong to me

 

 

 

 

 

 

 

 

 

 

 

 
  1. The thought of some defects of my body torments me so much that it prevents me having a sexual life

 

 

 

 

 

 

 

 

 

 

 

 
  1. I observe myself in what I do and ask myself how I seem to others

 

 

 

 

 

 

 

 

 

 

 

 

 
  1. I would like to decide what  appearance to have

 

 

 

 

 

 

 

 

 

 

 

 
  1. I feel different to how others see me

 

 

 

 

 

 

 

 

 

 

 

 
  1. I am ashamed of my body