Bariatric Patient Questionnaire

Thank you for your interest in our bariatric surgery program. As you may have already discovered, the evaluation for this type of procedure can be quite complex and difficult. These questions are designed to help speed up your evaluation and assist in insurance authorization. Please answer these questions to the best of your ability.

Patient Information:
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Emergency Contact:
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Allergies, Reactions and Habits:
Do you use tobacco?

Do you drink alcohol?

For Women Only:
Are you currently taking birth control?

Medical History - Related to Obesity:
Check all related to obesity



Do you have Diabetes?

Insulin?

Sleep Apnea (Check all that apply)


Use the BMI Calculator (Opens in a new window).
Other Medical History:
Check all that apply:





Check or list any prescription medications taken for weight loss:


Family Medical History:
Diet History:
Interests:
I am interested in: Check all that apply


How did you hear about us?
 
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