Bariatric Surgery Intake Form

The Bariatric Surgery Intake Form is purpose-built for bariatric and metabolic surgery programs, capturing the comprehensive medical, nutritional, and psychosocial history that bariatric surgeons and multidisciplinary teams need for surgical candidacy evaluation and perioperative planning. This template collects patient demographics alongside a detailed weight history including current weight, highest lifetime weight, weight at age 18, BMI calculation, duration of morbid obesity, and weight trajectory over the past decade. The obesity-related comorbidity assessment systematically screens for type 2 diabetes (with HbA1c, medication regimen, and insulin requirements), obstructive sleep apnea (with CPAP compliance and AHI from polysomnography), hypertension, dyslipidemia, non-alcoholic fatty liver disease (NAFLD/NASH), gastroesophageal reflux disease, osteoarthritis, stress urinary incontinence, polycystic ovarian syndrome, and pseudotumor cerebri.

Designed for MBSAQIP-accredited bariatric surgery centers, metabolic surgery programs, and multidisciplinary weight management clinics, this form includes sections for prior weight loss attempts (commercial diet programs, physician-supervised medical weight management, pharmacotherapy with specific agents such as GLP-1 receptor agonists, phentermine, or orlistat, very low-calorie diets), prior bariatric or gastrointestinal surgical history, nutritional assessment (current dietary patterns, eating behaviors, binge eating screening, history of eating disorders, vitamin and mineral supplementation), and a comprehensive surgical risk assessment including venous thromboembolism risk, functional status, cardiopulmonary evaluation, and the Obesity Surgery Mortality Risk Score (OS-MRS).

The psychosocial readiness section captures the patient's understanding of surgical options (Roux-en-Y gastric bypass, sleeve gastrectomy, duodenal switch, adjustable gastric band revision), realistic outcome expectations, support system, psychiatric history (depression, anxiety, substance use, history of self-harm), compliance with pre-operative program requirements (nutritional counseling sessions, psychological evaluation, supervised weight loss period), and insurance authorization documentation. All fields are HIPAA-compliant and meet the documentation requirements for insurance pre-authorization, which typically requires demonstration of medical necessity through BMI criteria, comorbidity documentation, and evidence of prior supervised weight loss attempts.