Medical & Mental Health History
Congratulations on taking the next step in improving your health! We welcome you to our program and thank you for completing the attached questionnaire to the best of your ability. Please bring this to your first appointment, we look forward to serving you! If you have any questions, please don’t hesitate to call our office: 208-782-3993
Please list any providers that contribute to your care:
Please include any medications that are only taken as needed.
Please list any medications you are currently taking to treat mental health issues. Also include any medications that you previously took and stopped.
Accurate history of previous attempts at weight loss are very important in obtaining insurance approval for surgical or non-surgical weight loss. Do your best to provide as much information as possible:
Physician or Dietitian Supervised Weight Loss
No, please skip to next section
None, please skip to the next section
*Please include any endoscopy procedures (EGDs)
Please indicate if you have experienced any of these issues in the past 60 days:
Please indicate any medical issues that you are currently treating or have treated in the past. These are very important to insurance companies and also to your safety in undergoing surgery.
Do you experience any of the following:
If you haven't been diagnosed please complete our sreening in the next section.
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you have not done some of these things recently, try to work out how they would have affected you.
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Please use the above scale to choose the most appropriate number for each situation.