Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Bariatric Surgery Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Current Weight & Height
Weight History Timeline
Obesity-Related Comorbidities
Diabetes & Metabolic Status
Additional details
Sleep Apnea & CPAP Status
Prior Weight Loss Attempts
Prior Bariatric/GI Surgery
Nutritional Assessment
Eating Behavior Screening
Current Medications
| Medication | Dose | How often |
|---|---|---|
Surgical Risk Assessment
Psychiatric History
Additional details
Psychological Evaluation Status
Support System & Lifestyle
Preferred Surgical Procedure
Please bring to your visit: insurance pre-authorization docs
Insurance Information
Bariatric Surgery Intake Form template from formisoft.com. formisoft.com/intake-templates/bariatric-surgery-intake