Contact Information:

First Name *

Last Name *

Birthdate *

MM-DD-YYYY

Ethnicity

Gender

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Primary Phone *

Email *

Secondary Phone

Insurance Information:

Current Insurance Carrier *

Policy Number

Group Number

Subscriber Name

Subscriber Date of Birth

MM-DD-YYYY

Customer Service Phone Number

Provider Service Phone Number

Secondary Insurance Information:

Secondary Insurance Carrier

Secondary Insurance Policy Number

Secondary Insurance Number

Subscriber Name

Customer Service Phone Number

Provider Service Phone Number

Questionnaire:

Have you reviewed the bariatric surgery informational video? *

How interested are you in moving forward with bariatric surgery? *

Have you had bariatric surgery in the past? If yes, which one? *

Are you experiencing a complication from a previous bariatric surgery? If so, what are you experiencing?

Height *

Weight *

How many years have you had trouble with your weight?

Is there a specific life event that exacerbated your trouble with weight? (ex: childbirth, divorce, menopause)

List all diets you have tried in the past (ex: Weight Watchers, Nutrisystem, Atkin’s Diet, HMR, low carbohydrate, low fat, high protein, calorie counting)

List all forms of exercise you have tried in the past (ex: running, walking, weightlifting)

Have you worked with a physician and/or dietitian for weight loss in the past?

List all medications you have taken for weight loss in the past:

List any medications you are currently taking for weight loss:

What is the most weight you have been able to lose in the past?

How many years were you able to keep the weight off?

Have you ever had a heart attack?

Have you ever had a stroke?

Have you ever had a blood clot in your veins, legs, or lungs?

Do you take any blood thinning medications?

Do you take insulin?

Are you on supplemental oxygen at home?

Do you use a CPAP or bipap?

Are you on dialysis?

Can you walk unassisted?

If you need assistance walking, what device do you use?

Are you currently under the care of a mental health provider?

Have you ever been hospitalized for a psychiatric issue? If so, what years?

Have you ever attempted suicide? If so, what years?

Have you ever been treated for an eating disorder? If so, what year?

Do you currently force yourself to vomit after eating?

List any other medical conditions:

List any prescribed medications:

List any allergies you have:

Social History:

Do you smoke nicotine products (cigarettes, cigars, etc.)? *

Have you smoked in the past? *

If so, when did you quit smoking?

For how many years did you use tobacco?

Do you vape and/or use smokeless tobacco products? *

Do you use marijuana? *

Do you use street drugs? *

How many times per week do you consume alcohol?

Advanced Bariatric Surgery and Medical Weight Loss – Appointment Form

This seminar is an introduction to advanced bariatric surgery options and benefits.
The video is required to be viewed before scheduling a consultation.

Patient Form (To be completed after seminar video)

Contact Information:

Insurance Information:

Secondary Insurance Information:

Questionnaire:

Medical History:

Surgical History

Social History:

Advanced Bariatric Surgery and Medical Weight Loss – Appointment Form

This seminar is an introduction to advanced bariatric surgery options and benefits. The video is required to be viewed before scheduling a consultation.

Patient Form (To be completed after seminar video)

Contact Information:

Insurance Information:

Secondary Insurance Information:

Questionnaire:

Medical History:

Surgical History

Social History:

This seminar is an introduction to advanced bariatric surgery options and benefits.
The video is required to be viewed before scheduling a consultation.