Bariatric Procedure Psych Evaluation Questionnaire
Please complete ONLY IF you are being seen for a one time psychiatric evaluation for a Bariatric procedure.
Date of Birth
Ex: 5 ft, 5 inches
Ex: XXX lbs
Please list any diets or medications that you have tried in the past for weight loss:
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?
Should be Empty: