Bariatric Evaluation Questionnaire

Bariatric Evaluation
IDENTIFYING INFORMATION
Name*
Gender*
Age*
Birthdate*

MonthDayYear
Date
What type of bariatric surgery are you planning on having?*
Who is your referring provider?*
Your current weight*
Your height*
Your ideal weight*
When was the last time you weighed your ideal weight?*
What is specifically motivating you to lose weight now?*

0/250
What makes this a good time in your life to lose weight?*

0/250
People who want to achieve long-term weight control need to spend at least 30 minutes a day, for a minimum of 6 months, trying to change their eating, exercise, and thinking habits.
Please choose the option below that best describes you:*

I definitely will not be able to devote 30 minutes daily to weight control.I'm not sure if I can find 30 minutes daily for weight control.I can definitely find 30 minutes daily for weight control.I can devote more than 30 minutes daily to weight control.
Rate how confident you are that you will be able to significantly change your eating and exercise habits. Pick a number from 1 to 10 in which 1 = “not at all confident” and 10 = “extremely confident.” Your number is:*
At what age were you first overweight by 10 pounds or more?*
What has been your highest weight after age 21? number of lbs* lbs at age* years old.
What has been your lowest weight (not due to illness) that you have weighed after age 21? number of lbs* lbs at age* years old.
Maintained for number of years years.
Was this weight reached through a weight loss effort?*

YesNo
If yes, how did you reach this weight? Please describe:

0/250

Weight Loss Attempts: Make a list of the diets, medications, and/or other measures you have tried, how old you were when you tried them, when you tried each one, how much weight you lost, the length of time the weight stayed off, and how much weight you gained back.

Weight Loss Attempts*

	Weight Loss Effort	Age	Start and Stop Dates	Pounds Lost	Time Weight Kept Off	Weight Regained
Attempt 1
Attempt 2
Attempt 3
Attempt 4
Attempt 5
Attempt 6
Attempt 7

LIFESTYLE BEHAVIORS
How physically active are you?*

ActiveAverageInactive

What do you do for physical activity, how often, and for how long each time?

	Activity	Frequency (how often)	Duration (how long)
Activity 1
Activity 2
Activity 3
Activity 4

	Medication Name	Prescribed/Taken for
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8

	Reason for Contact	Approximate Date(s)
counseling service 1
counseling service 2
counseling service 3
counseling service 4

	Child's Age	Child's Sex	Overweight	Average	Underweight
Child 1
Child 2
Child 3
Child 4
Child 5

	Sibling's Age	Sibling's Sex	Overweight	Average	Underweight
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Sibling 5

Bariatric Evaluation

Center for Psychological Well-Being Bariatric Evaluation

LIFESTYLE BEHAVIORS

Center for Psychological Well-Being Bariatric Evaluation

PERSONAL INFORMATION QUESTIONNAIRE

MEDICAL HISTORY

Center for Psychological Well-Being Bariatric Evaluation

PERSONAL INFORMATION QUESTIONNAIRE

SUBSTANCE USE

Center for Psychological Well-Being Bariatric Evaluation