New Life Patient Weight Loss & Medical History Questionnaire

New Life Patient Weight Loss & Medical History Questionnaire
Name

First NameLast Name
Sex
DOB

MonthDayYear
Date
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Current Weight:
Current Height:
BMI:
INSURANCE INFORMATION
Insurance Name
Does your Health Insurance cover weight loss surgery?
If so what Pre-Approval Requirements do they have ?
Pre-Op weight loss required? How many lbs?
Is a Medically Supervised Weight Loss Program required?
If a Medically Supervised Weight Loss Program is required, what is the length of time required?
Duration of Obesity?
Is smoking cessation required?
Is Mental Health Clearance required?
Is psychological or IQ testing required?
Other Requirements?
PREVIOUS ATTEMPTS AT WEIGHT REDUCTION:
How many years have you been overweight?
Estimated weight at Birth?
Estimated weight at Marriage?
Lowest Weight in Past 5 Years?
Highest Weight in Past 5 Years?

PREGNANCY WEIGHT?

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).

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

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

Rows	Dates	Duration	MD Supervised?	Weight Loss
Amphetamines
Phentermine (Adipex, Fastin, Pondimen)
Phen-Fen
Dexfenfluramin (Redux)
Xenical (Orlistat)
Meridia (Sibutramin)
Ozempic/ Wegovy
Mounjaro / Zepound

Please indicate if you have tried any of the following weight loss therapies:

Tell us about your previous weight loss surgery:

Rows	Type	Date	Surgeon	Weight Loss
Surgery

Non-Dietary Therapy