• New Life Patient Weight Loss & Medical History Questionnaire

  • Sex
  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

  • Does your Health Insurance cover weight loss surgery?

  • If so what Pre-Approval Requirements do they have ?

  • Is a Medically Supervised Weight Loss Program required?
  • Is smoking cessation required?
  • Is Mental Health Clearance required?
  • Is psychological or IQ testing required?

  • PREVIOUS ATTEMPTS AT WEIGHT REDUCTION:

  • PREGNANCY WEIGHT?
    Rows

  • FOOD PREFERENCES

  • Rate the following foods from 1-5. 1 for Don't Like Very Much, and 5 for Live Very Much (most likely to make you go off a diet).
    Rows

  • DIET PROGRAMS AND SUPPLEMENTS

  • Please indicate which of the following diets or plans you have tried:
    Rows

  • WEIGHT-LOSS MEDICATION HISTORY

  • Please indicate if you have taken any of the following medications to lose weight:
    Rows

  • Non-Dietary Therapy

  • Please indicate if you have tried any of the following weight loss therapies:
    Rows
  • Previous Weight Loss Surgery?*
  • Tell us about your previous weight loss surgery:
    Rows
  • Should be Empty: