Bariatric Surgery Assessment

1

By completing this assessment, I agree to allow Forrest General Hospital and Hattiesburg Clinic Weight Management access to my assessment answers for marketing purposes.

2

Are you 18 years old or over?

Yes

No

3

Have you ever tried formal weight loss plans?

Yes

No

4

Have you ever used diet medications in the past?

Yes

No

5

Do you currently exercise? If so, how often?

One time per week

Three times per week

Less than one time per month

No current exercise routine

6

Are you a smoker?

Yes

No

8

Do you have any of the following conditions? Select all that apply.

High Blood Pressure

High Cholesterol

Sleep Apnea

Arthritis

Diabetes

9

Name

First Name

Last Name

10

Phone Number

Please enter a valid phone number.

11

Email

example@example.com