Personal Data
Primary Care Physician & Preferred Pharmacy
Medications, Supplements & Allergies
Be sure to include all prescription medications, over-the-counter, diabetic, and vitamins/dietary supplements.
5 Year Weight History
Please provide your highest weight in the last 5 years.
This year, my weight is (weight in pounds)* Year 1 prior, my weight was (weight in pounds) Year 2 prior, my weight was (weight in pounds) Year 3 prior, my weight was (weight in pounds) Year 4 prior, my weight was (weight in pounds)
Past Medical History
Please mark all conditions current and/or past that applies
in the various sections below.
Past Surgical History
Family Medical History
Please mark any condition(s) that have been diagnosed in your family such as biological parents, grandparents, and siblings. Check all that apply.
Physical Exercise Assessment
Sleep Apnea Assessment
Testing for Sleep Apnea may be required to obtain clearance for bariatric surgery. Answers should be accurate, as inaccurate or incomplete answers may delay our ability to process &/or obtain insurance authorization.
The study was done on Month/Year in City, State.
This is a fill in the blanks field. Please add appropriate blank fields and text.