Gastric Bypass Questionnaire

GENERAL INFORMATION

Name*

Email*

Phone*

WEIGHT HISTORY

Please answer the following questions in as many details as possible:

Describe any past and current Illness history:*

What is your current weight and BMI?*

Briefly describe your daily/past eating and exercise patterns.*

Describe your weight history from childhood throughout your adulthood.*

Describe all Commercial Weight Loss Programs you have partaken in i.e., date started, dates stopped, time used, pounds lost, and results.*

Describe any family history of obesity ( family i.e., parents, siblings grandparents only):*

List any and all allergies:*

Past Medical History Surgery:*

SOCIAL HISTORY

Describe your social history as it relates to the following:

Alcohol Abuse*

Substance Abuse*

Tobacco Abuse*

Domestic Abuse*

Why are you pursuing this surgery/procedure?*

Verification