Bariatric Procedure Psych Evaluation Questionnaire
Please complete ONLY IF you are being seen for a one time psychiatric evaluation for a Bariatric procedure.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Height
*
Ex: 5 ft, 5 inches
Weight
*
Ex: XXX lbs
Please list any diets or medications that you have tried in the past for weight loss:
*
*
Yes
No
1. Would you say that food dominates your life?
2. Have you made yourself vomit to counteract the effects of eating, or made yourself vomit because you feel uncomfortably full?
3. Have you used laxatives or diuretics to prevent weight gain, or counteract the effects of eating?
4. Have you engaged in excessive exercise specifically to counteract the effects of eating?
Which procedure are you being evaluated for?
*
Gastric Bypass
Gastric Sleeve
Other
Submit
Should be Empty: