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Bariatric Surgery Questionnaire

This 5-part questionnaire will help us learn more about you and help us establish your best path to weight loss. The form must be completed prior to scheduling your first appointment. A printable version of this form can be found here. For questions, please call 585-341-0366.

Contact Information

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Have you completed a bariatric seminar?

STOP! Before completing this form please attend a Bariatric Seminar.

The first step in your weight loss journey will be to complete or schedule to attend a bariatric seminar. This comprehensive seminar will provide you with all the information you'll need in the weeks and months ahead.

Sign up for a free Seminar today!

Part 1: Medical History

Please check condition that applies to you:

Have you ever had surgery?

Select any surgery that applies to you:

What type of Bariatric Surgery did you have?

Indicate any known family history:

Anesthesia Allergy






Diabetes Type 1

Diabetes Type 2

Early Death

Heart Disease

High Blood Pressure

High Cholesterol

Kidney Disease

Mental Illness

Morbid Obesity



Polyps on Colon

Lung Cancer

Who has this condition

Are you disabled?
Reason Disabled (check all that apply)

Do you currently use an assistive device?

Can you independently perform acts of daily living? (bathing, toileting, getting dressed, etc.)
Do you perform any additional exercise? (Check all that apply)

Functional Limits (check all that apply)

Part 2: Social History

Do you drink alcohol?

Please indicate the amount you drink each week:

Do you currently use illicit/street drugs? (including medical marijuana)

How many times/week?

Do you use tobacco products?
Are you a smokeless tobacco user?
Sexually Active?
Birth Control | Protection

Part 3: Medications, Vitamins, & Allergies

Do you take any medications or vitamins?

Please list below all Medications and Vitamins you are currently taking. Ex. Lipitor, 10mg, one tablet daily at bedtime

Name Dose Frequency


Please list any allergies and reactions you may have

Allergy Reaction

Part 4: Sleep Assessment

Answer the following questions based on your current sleep situation.

How likely are you to doze off in these situations?

Situation Chance of Dozing
Sitting and reading
Watching TV
Sitting, inactive in a public place (ex. in a movie theater or a meeting)
As a passenger in a car for an hour or more
Lying down to rest in the afternoon
Sitting and talking
Sitting quietly after lunch (without alcohol consumption)
While driving a car, while stopped for a few minutes in traffic
How frequently do you snore or have you been told you snore loud enough to disturb other’s sleep?

How often have you been told you pause or stop breathing while sleeping?

Do you sleep during the day?
Do you sleep excessively?

Part 5: Weight Loss History

Have you been morbidly obese for more than 5 years?
Have you been obese since childhood?
Have you been obese since pregnancy?

Tell us about your previous weight loss attempts:

Have you taken weight loss medications?

What diet programs have you tried?

Only document your weight loss attempts in the past 5 years

Diet Program Number of Months Weight lost Physician Supervised? Year
Jenny Craig
LA Weight Loss
Weight Watchers
South Beach
Registered Dietitian
Optifast/ Medifast
Calorie Controlled

You have reached the end of the questionnaire, please click submit to take the next steps in your journey.


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