Select Yes or No if you have ever had the following conditions / illnesses.
Please explain any check from above starting with the number, identify if
this is a current or past problem:
Hospitalizations and Surgeries
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.
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
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.
Please list any treatments for weight loss or eating in which you have participated for more than 1 month.
Diets (Calorie counting, Weight Watchers, Jenny Craig, Atkins, Diabetic, Paleo, etc.
Diet Pills/Supplements (Over-the-counter supplements such as Ali, Fat Burners, Dexatrim etc.)
Prescription Medications (Phentermine, Wellbutrin, Topomax, Orlistat, etc.)
Medically Supervised Programs (Liquid protein diets, Psychotherapy, Dietitian Counseling)
Other (Weight Loss Surgery, Exercise Programs, Overaters Anonymous, etc.)
Please try to give as much specific information as possible.
Name of Method:
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
As part of The Bariatric Center Program, we will periodically obtain