2026 Bariatric New Patient Questionnaire JOTFORM

  • Language Notification/ Notificación de idioma. (English)

  • This is a very thorough medical and dietary questionnaire. You can save your progress to continue later. It is required that this be completed before we can schedule your services with the dietitian. 

  • Are You Actively Seeking Weight-Loss Surgery?

    Primary or Revisional
  • Patient Type*

  • Thank you for your inquiry. This form is designed for patients actively seeking primary or revisional weight-loss surgery. Because you answered that you are not pursuing surgery at this time, it is not necessary to complete this intake form.  Please visit our website at https://nutrition5.com/services/  for a complete list of services we offer, or call 443-490-1240 to leave a message and have our team contact you to schedule. 

    If you feel this was a mistake and you are in fact seeking weight loss surgery, please select the "Back" button to change your previous response. 

    Thank you! 

    GIBNC

  • Patient Information

  • Today's Date
     / /
  • Date of Birth*
     - -

  • Contact Information

  • Is your mailing address different than above?*

  • Your valid email address is vital.

    We use it to send you information for registering and logging in to our portal for your online classes, appointment reminders, copies of your paperwork, and digital materials.  Please provide one that you check often.  

    Add OFFICE.COMMUNICATION@GIBNC.NET to your safe senders; this is where our office will email you from.  Please check SPAM. 


  •

  • Your cell phone number is important.

    We use it to send you appointment reminders, links to classes and communicate with our administrative staff. 

    Add 240-452-0422 to your safe senders; this is where our office will send SMS text messages to you.  Please check your UNKNOWN SENDERS Text message inbox. 

  • Consent to send Appointment Reminder SMS Text Messages (NOT used for marketing)*

  • Bariatric Surgeon Appointment

  • Have you seen your bariatric surgeon in the past 12-months?*

  • You answered NO to having seen the bariatric surgeon in the past 12 months.

  • Are you scheduled to see the surgeon in the future? If so, please indicate the date. *
     - -

  • Select your bariatric surgeon

  • Do we have permission to release your information to your surgeon & referring physician(s), when appropriate, in order to better coordinate your care? *
  • Referring Surgeon*

  • St Agnes Medical Group Patients

  • Patients of surgeons other than those with St. Agnes Medical Group

  • Insurance Information

  • Do you have secondary insurance? *

  • Goals and Readiness Assessment

  • Gender assigned at birth*

  • Female at Birth Questions

  • Menstrual Cycle*
  • Do you plan to get pregnant within the next 12 months? *

  • Medical History

  • Comorbidities

  • Check ALL "comorbidities" that apply or NONE*

  • Digestive Disorders

  • Check ALL digestive disorders that apply or NONE*

  • OTHER Conditions

  • Check ALL other conditions that apply or NONE*

  • Surgical History

  • Digestive Surgical History*
  • Have you had previous weight-loss surgery?*

  • Prior Weight-Loss Surgery information

  • Original Surgery Date*
     - -

  • Revision Surgery Medical History

  • Head

  • Do you have any of the following issues (head)?*

  • Heart

  • Do you have any of the following issues (heart)?*

  • Weight

  • Do you have any of the following issues (weight)?*

  • Emotions

  • Do you have any of the following issues (emotions)?*

  • Eyes

  • Do you have any of the following issues (eyes)?*

  • Digestive

  • Do you have any of the following issues (digestive)?*

  • Energy / Activity

  • Do you have any of the following issues (activity)?*

  • Endocrin

  • Do you have any of the following issues (endocrin)?*

  • Musculoskeletal

  • Do you have any of the following issues (joint/muscle)?*

  • Memory

  • Do you have any of the following issues (memory)?*
  • Do you have any of the following issues (other)?*

  • Smoking History

  • Do you SMOKE cigarettes or vape?*

  • FOOD ALLERGIES AND INTOLERANCES/EATING HABITS HISTORY

  • Rows
  • Food Intolerances*
  • If you follow a special diet/nutritional program check all that apply/ and that you look for on labels currently and any specialized diet you may be following:*
  • Do you follow any special diet or have diet restrictions or limitations for any reason (health, cultural, religious, or other)?*

  • Digestive History

  • Do you take laxatives?*
  • Image field 365
  •

  • Digestive Symptom Checker

  • Rows

  • Eating Disorder History

  • Have you had any history of and been diagnosed with an eating disorders? (Ex. Binge eating and then vomiting, Binge eating compulsively large quantities of food without vomiting, Waking up and eating late at night, or not eating or eating very little for long periods of time)? *

  • Eating Disorder Details

    You answered YES to having been diagnosed with an eating disorder, please complete the details below. If this is a mistake, please hit the BACK button to change your response.
  • What eating disorder(s) do you have?*
  • Night Eating: Do you wake up in the middle of the night hungry?*
  • Do you remember what you eat?
  • Binge Eating - How often do you binge?
  • Was the disorder professionally diagnosed by a medical professional? *
  • Were you professionally treated?
  • Is the disorder still present at this time*

  • Vitamins and Minerals

  • What vitamins and supplements are you currently on? Check ALL that apply (if NONE check NONE)*

  • If "other" above please list here.      fields and text.

  • PATIENT SPECIAL NEEDS

  • Do you have any special needs with vision, hearing, reading, traveling to appointments, or grocery shopping?*

  • What special needs to you have?

    You answered YES on the previosu page to having sprcial needs, please complete the below information. If this is mistake, please hit the BACK button to change your response.
  • If YES, Is there a support person assisting the patient with:*
  • Please check all special needs that apply or NONE*
  • If the patient is hearing impaired, do they read English proficiently (ex. Closed Captioning, documents, etc.)*

  • Fluids & Foods

  • Fluids

  • Rows
  • Rows
  • Rows
  • Rows
  • Rows

  • Foods

  • Rows

  • Eating Habits

  • Eating Style: based on how you eat on a regular basis, please check ALL that apply*

  • Physical Activity

  • Do you regularly exercise now?*

  • Exercise Type

  • Rows
  • Rows
  • Are there any medical reasons why you cannot or should not exercise?*

  • Medical reasons for not exercising

  • Authorization to Release and Discuss Medical Records

  • Please select your surgeon below whom you are authorizing GIBNC to release medical records to.*
  • Unless othewise checked below, you agree to have all medical records released to GIBNC: (CHECK ALL THAT APPLY)*
  • Information to be disclosed (check all that apply):*

  • This authorization shall expire one year from the date of signature for Maryland medical records. PLEASE NOTE: If you are a minor child, the expiration date cannot exceed your eighteenth (18) birth date, at which time a new authorization will need to be completed if desired. Please initial below.

  • By signing below, the beneficiary or the beneficiary's representative agrees to the following statements: 


    I understand that my health care will not be affected if I do not sign this form. 
    I understand that I may see and copy the information described on this form if I ask for it, and that I get a copy of this form after I sign it.  
    I understand that I may revoke this authorization at any time.  I understand that to revoke this authorization, I must do so in writing and send my revocation to GIBNC at the address above.  I understand that the revocation will not apply to information already released in response to the authorization.
    I understand that once the information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient, and the information may not be protected by federal privacy regulations. 
    I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the Regulations. 

    Maryland law prohibits any person from redisclosing medical information without the patient's authorization.  This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. 


    If you are a parent/Court appointed guardian of a minor child, your signature is required together with that of the minor child.  If you are a court-appointed guardian of a disabled adult or an authorized representative acting on behalf of a physician-certified incapacitated beneficiary, your signature is required as the beneficiary's authorized representative.  A complete copy of any legal documents, and if applicable, a certified physician statement granting you the authority to act on this individual's behalf will need to be attached to the form.


    Various states allow a beneficiary, younger than age 18, to seek health care services regarding sensitive diagnoses, such as Pregnancy and Birth Control, Abortion, AIDS and STDs, Mental Health and Alcohol and Substance Use, without the consent of a parent or court-appointed guardian.   Therefore, before any sensitive health information is disclosed, this form must be signed and received from the beneficiary by a parent or guardian.


    I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization.  My refusal to sign will not affect my ability to obtain treatment.  By signing below, I represent and warrant that I have the authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information. 

     

  • *   *      Pick a Date*    Authorization to Release

  • HIPAA

    Patient Health Information Consent Form (PHI)

  • *   *      Pick a Date*    HIPAA

  • Requirements to be cleared for bariatric surgery:

  • *   *      Pick a Date*    Requirements for Clearance

  • Supervised Weight Loss Documentation:

  • Please select one option below for the weight-documentation requirements.*

  • Weight Documentation COMPLETED

  • When did you complete your documentation? If the day is unknown use "01" for the day. *
     - -

  • Weight Documentation IN PROGRESS

  • When did you START your weight-loss documentation? If the exact day is unknown, enter "o1 " for the day. *
     - -

  • Supervised Weight-Loss Documentation with GIBNC

  • *   *      Pick a Date*    Weight Documentation with GIBNC

  • Financial Policy

    Thank you for choosing The GI and Bariatric Nutrition Center. The following is a statement of our Financial Policy and applies to GIBNC and all subsidiaries, which we require that you read and sign prior to your first scheduled service.  

  • Payment Methods Accepted

  • Insurance

  • Missed Appointments & Classes

    We strictly adhere to this policy.

  • Late Payment Fees

  • Services/ Time Limitations

  •          Pick a Date*           Financial Policy

  • PATIENT AGREEMENT REGARDING MATERIALS

  • *   *      Pick a Date*    Materials Agreement

  • Text Message Alerts

    SMS messages will come from 240-452-0422 - please add this to your GIBNC Contact

  • Notices & Disclosures

  • Data Accuracy and Completeness Acknowledgement

  • Misrepresentation

  • Consent to Electronic Delivery

  • Electronic Signature Agreement

  • *   *      Pick a Date*    Notices & Disclosures

  • How to Contact Us

  •  

    🌐 www.nutrition5.com 

    📞 Phone: 443-490-1240

    📠​ Fax:     443-490-5060

    💬 SMS Messaging with schedulers: 240-452-0422

    📧 Email: www.nutrition5.com/contact-us 

     

    Social Media

    ​​​Facebook: https://www.facebook.com/GIBNC/

    Instagram: https://www.instagram.com/gibnc_ANRP/ 

    TikTok:     https://www.tiktok.com/@gibnc5 

    Pinterest: https://www.pinterest.com/gibnc/ 

     

     

  • To submit your questionnaire please sign and date below, then click on the submit button. Don't forget to check your email for an email from office.communication@gibnc.net for your next steps. And follow the instructions on the pop-up screen after your submission is accepted. Thank you!

  • *   *      Pick a Date*   Form Submission

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