Patient Registration

All information is confidential. Please answer honestly to assure the best possible treatment for you. Please complete steps 1 - 5, you may move freely between them below. You can submit the form on the last step.

Personal Information
Are you attending a medically supervised weight loss information session? Yes or No
If so, list the date of the info session you are attending:

Emergency Contact Information
Personal Physician Information
Insurance Contact Information
Health Habits


If yes, list:
Allergy Describe Reaction

Please list all medications you are currently taking or have taken in the last 30 days including: vitamins, birth control pills, herbal medications, etc. Include actual dosages and frequency below:

Medication Dosage Frequency
For Women Only

Illness History Select Yes or No if you have ever had the following conditions / illnesses.
General Illnesses Yes No
1. Serious infectious disease, tumors/cancer
2. Skin problems/rashes
3. Sinus problems, nosebleeds
4. Hay fever
5. Ear infections
6. Eye problems
7. Hoarseness
Respiratory Yes No
8. Asthma/wheezing
9. Emphysema
10. Pneumonia/Bronchitis
11. Cannot breath lying flat
12. Shortness of breath
13. Frequent coughs/colds
14. Coughing up blood/mucus
15. Soaking night sweats
Cardiovascular Yes No
16. Heart valve problems
17. Chest pain
18. Heart attack
19. High blood pressure
20. High cholesterol
21. Heart murmur
22. Varicose veins
23. Blood clots
24. Bleeding problems/anemia
25. Ever recieve a blood transfussion
26. Palpitation/Irregular heart rate
27. Pacemaker
28. Edema/Swelling
Gastrointestinal Yes No
29. Ulcers
30. Liver or Gallbladder problems
31. Bowel irregularities (Diarrhea/Constipation)
32. Abdominal pain
33. Frequent heartburn
34. Frequent vomiting/nausea
35. Bloody stool/urine
Urinary Yes No
36. Kidney stones
37. Frequent urination
38. Bladder control problems/stress/incontience
39. Painful urination
Muscular Yes No
40. Bone/joint problems
41. Back/neck pain
42. Arthritis/gout
43. Knee/Hip surgery
Neuro Yes No
44. Numbness/tingling in hands or feet
45. Dizziness
46. Stroke
47. Seizures
48. Sleep Apnea
Endocrine Yes No
49. Diabetes
50. Thyroid Problems
51. Tiredness/Fatigue
Emotional Yes No
52. Depression or emotional problems
53. Anxiety/Stress
54. Other:
Please explain any check from above starting with the number, identify if this is a current or past problem:
Hospitalizations and Surgeries
Surgeon Place of Surgery Date (if known)

If yes, list:
Type Surgeon Date Results
Family History




Father's Father:

Father's Mother:

Mother's Father:

Mother's Mother:


Thrombosis Risk Factor

Please read the list of risk factors below, and check all the factors that pertain to you. You will recieve a score at the bottom that indicates your risk based on these factors.

Risk Factor
Age above 40?
Previous blood clot in legs (DVT) or lungs (PE)?
Inability to walk more than a few steps?
Previous history of cancer?
Are you obese (BMI >= 35)?

Heart disease/Congested Heart Failure
Varicose veins
Limb trauma/injury
Undergoing surgery (including proposed Bariatric Surgery)
Hormone Replacement or Birth Control Pills
History of Auto Immune Disease (Lupus, SLE, Rheumatoid Arthritis)
Disease affecting the clotting of blood
Score:     0-1 = Low Risk, 2-4 = Moderate Risk, >4 = High Risk
Total Score: 
Sleep screening

Please read the questions below, and check as they apply to you. You will recieve a score at the bottom that indicates your risk based on these factors.

Do you snore?
If you snore, do others say your snoring is interrupted by choking or snoring sounds?
Do others say you stop breathing while you sleep?
Do you have trouble staying awake when you want to be awake?
Do you fall asleep during any of the following?

Do you fall asleep frequently while reading books or newspapers?
Have you ever fallen asleep while driving?
Do you have trouble getting to sleep or staying asleep when you want to sleep?
Do you feel tired after 8 hours of sleep?
Do you frequently get less than 7 hours of sleep in 24 hours?
Do you have restless or crawling feelings in your legs when you sit or lie down?
Do others say you have jerking movements of your legs during sleep?
Score:     5 or less = Low Risk, 5-8 = Moderate Risk, Above 8 = High Risk
Total Score: 

Weight loss History Please spend time completing this questionnaire in as complete detail as possible. This information is extremely important in determining your appropriateness for weight loss surgery.

Explanations Please list any treatments for weight loss or eating in which you have participated for more than 1 month.
  1. Diets (Calorie counting, Weight Watchers, Jenny Craig, Atkins, Diabetic, Paleo, etc.
  2. Diet Pills/Supplements (Over-the-counter supplements such as Ali, Fat Burners, Dexatrim etc.)
  3. Prescription Medications (Phentermine, Wellbutrin, Topomax, Orlistat, etc.)
  4. Medically Supervised Programs (Liquid protein diets, Psychotherapy, Dietitian Counseling)
  5. Other (Weight Loss Surgery, Exercise Programs, Overaters Anonymous, etc.)
Please try to give as much specific information as possible.

Name of Method: Date Tried: to
Weight Loss: Weight Gained: Results:

Name of Method: Date Tried: to
Weight Loss: Weight Gained: Results:

Name of Method: Date Tried: to
Weight Loss: Weight Gained: Results:

Name of Method: Date Tried: to
Weight Loss: Weight Gained: Results:

Name of Method: Date Tried: to
Weight Loss: Weight Gained: Results:

Name of Method: Date Tried: to
Weight Loss: Weight Gained: Results:

Name of Method: Date Tried: to
Weight Loss: Weight Gained: Results:

Name of Method: Date Tried: to
Weight Loss: Weight Gained: Results:

Eating Behavior History
  1. Have you ever had an episode of binge eating:
    1. Eating, in a 2-hour period, an amount of food that is definitely larger than most people eat in a smaller period? Yes or No
    2. A lack of control over eating during a meal/snack (i.e. a feeling that you cannot stop eating or control what or how much you eat)? Yes or No
  2. Please indicate on the scale below how characteristic the following symptoms are of your eating:
    Symptom Never Rarely Sometimes Often Always
    Feeling that I can't stop eating or control how much I eat
    Eating more rapidly than usual
    Eating until I feel uncomfortably full
    Eating large amounts of food when not feeling physically hungry
    Eating alone because I am embarassed by how much I am eating
    Feeling disgusted with myself, depressed, or very guilty after overeating
  3. Have you ever self-induced vomiting after eating in control to "get rid" of food?  Yes or No
  4. Have you ever used laxatives or diuretics to control your weight or "get rid" of food?   Yes or No
  5. On average, how many meals do you eat each day?
  6. On average, how many snacks do you eat each day?
  7. Do you avoid certain foods: Yes or No
    If yes, what?
  8. Please list all vitamins and supplements you take, even if not taken every day.
  9. Please answer the following:
    Have you ever... Yes - or - No Do you currently? How much? What type? How often?
    Smoked cigarettes or cigars
    Vaped or used E-cigs
    Chewed Tobacco
    Drank Energy Drinks
    Used caffeine tablets
    Drank coffee
    Drank tea
    Drank sodas
    Drank alcohol
    Exercised for health or weight loss
  10. Do you wear dentures? Yes or No
  11. Do you have difficulty chewing or swallowing? Yes or No
      a. If yes, explain:
Certification I certify that all the information I provide is true and complete to the best of my knowledge. I understand that it is important the physician has complete and accurate information in order to provide safe medical evaluation and care. I understand that this medical history is used in providing care through the Bariatric Center, and that some information may need to share with referring physicians/counselors.

As part of The Bariatric Center Program, we will periodically obtain pictures.