Bariatric Intake Questionnaire

NEW PATIENT CLINICAL QUESTIONNAIRE

Hoag Bariatric And Medical Weight Loss Program

I am interested in: (please check)

Bariatric Surgery

Medical (non-surgical) Weight Loss

PERSONAL INFORMATION:

Name

DOB (mm/dd/yyyy)

Age

Mailing Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Primary Language Spoken

Current Occupation

Marital Status

Number Of Children

Ages of Children

With whom do you reside?

If Other, please explain:

BARIATRIC BACKGROUND INFORMATION:

Have you had bariatric surgery before?

Yes	No

If YES, what type of surgery?

Have you done any research regarding bariatric surgery?

Yes	No

If YES, what type of research have you done?

How did you hear about this program?

Doctor	Friend	Internet	Other

If Other, please explain:

DIETING HISTORY:

Age you first started dieting:

Approx. weight at age 18:

What diets have you tried?

What weight loss medications have you tried?

In the past TWO years, which one of the following MD or nutritionist-supervised programs have you been on, for how long and how much weight did you lose?

Program

< 3 months

4-6 months

6 months +

I lost less than 10 lbs

I lost 10-20 lbs

I lost 20 lbs +

Jenny Craig

Nutri-Systems

Weight Watchers

OptiFast

Lindora

Fen/Phen Redux

Meridia

Xenical

Over The Counter Diet Aids

Atkins Diet

Ketogenic

Intermittent Fasting

Other

What was the most successful weight loss you achieved and how much weight did you lose? What was your age?

What behaviors did you learn from dieting that you still use today?

FOOD PREFERENCE:

Are you a sweet eater?

Yes	No

If so, what?

Frequency?

Are you a fast food eater?

Yes	No

If so, what?

Frequency?

Do you snack between meals?

Yes	No

If so, what do you snack on?

Frequency?

On a typical day, how much soda or other non-alcoholic beverages do you consume daily?

Beverage

None

8oz or less (1 can)

16-24oz (2-3 cans)

36-64oz

More than 64oz

Soda

Diet Soda

Juice

Crystal Lite or similar artificially sweetened drink

Sports Drink (i.e. Gatorade)

Energy Drinks (i.e. Red Bull, Monster)

Coffee

Decaf Coffee

Coffee Drink (i.e. latte, cappuccino)

What are you currently doing to encourage weight loss?

Endocrine History:

Insulin treated diabetes	Endocrine cancers (thyroid, adrenal, pituitary, etc)
Oral medication treated diabetes	Hypoparathyroidism
Hyperlipidemia (cholesterol/other lipids)	None of these
Hyperthyroidism	Other
Hypothyroidism

Musculoskeletal History:

Musculoskeletal Pain

Current alcohol history:

Alcoholic Beverage

None

Less than 5 drinks/week

More than 6 drinks/week

Beer

Wine

Other Liquor

I have a history of alcohol abuse in the past:

Yes	No

If past user and have quit, please indicate year/age of past use:

Current tobacco/nicotine history:

Nicotine Product

None

Less than a pack/roll/box per day

Cigarettes

Cigars

Vaping

Chewable Tabacco

If past user and have quit, please indicate year/age of past use:

Marijuana / Drug Abuse

Do you currently use drugs including medical marijuana?

Yes	No

If yes, please elaborate on the type and amount:

I have a history of drug abuse in the past:

Yes	No

If past user and have quit, please indicate year/age of past use:

Exercise:

Do you exercise regularly?

Yes	No

Do you have any physical restrictions that keep you from exercising?

Yes	No

What is the reason for your physical exercise restrictions?

SOCIAL / FAMILY HISTORY (cont.):

Having a support system when participating in any weight loss program is vital to successful and safe outcomes.

We believe it is important to discuss and confirm a patient's support system prior to beginning a medical (non-surgical) or surgical weight loss program.

Please mark all that apply:

What are your primary goals and reasons to pursue weight loss surgery?

What are your greatest fears and concerns about weight loss surgery?

Additional Information:

EPWORTH SLEEPINESS SCALE

How likely are you to doze off or fall asleep in the following situations?

Answer considering how you have felt over the past week or so.

0 = Would never doze

1 = Slight chance of dozing

2 = Moderate chance of dozing

3 = High chance of dozing


	1. Sitting and Reading							Increase valueDecrease value
	2. Watching TV							Increase valueDecrease value
	3. Sitting inactive in a public place (e.g., theater or meeting)							Increase valueDecrease value
	4. As a passenger in a car for an hour without a break							Increase valueDecrease value
	5. Lying down to rest in the afternoon when able							Increase valueDecrease value
	6. Sitting and talking to someone							Increase valueDecrease value
	7. Sitting quietly after a lunch without alcohol							Increase valueDecrease value
	8. In a car while stopped for a few minutes in traffic							Increase valueDecrease value


		My Sleep Score:
		Increase valueDecrease value

Title *
Patient Name
DOB
Age
Gender
Mailing Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Language
Email
Occupation
Marital Status
Children
Children Ages
Residence
Residence Other
PCP Name
PCP Company
PCP Address
PCP City
PCP State
PCP Zip Code
PCP Phone Number
PCP Fax Number
PCP Email
MD Name
MD Company
MD Address
MD City
MD State
MD Zip Code
MD Phone Number
MD Fax Number
MD Email
Insurance Name	Your name as it appears on your insurance card
Insurance Type
Insurance Company
Insurance Medical Group Number
Insurance Group Number
Insurance Member ID
Insurance Phone Number
Surgery Contemplation
Surgery Research
Surgery Research Type
Program Referrals
Program Referrals Other
Diet Age
Weight At 18
Past Diets
Jenny Craig
Nutri-Systems
Weight Watchers
OptiFast
Lindora
Fen/Phen Redux
Meridia
Xenical
Over The Counter Diet Aids
Atkins Diet
Ketogenic
Intermittent Fasting
Other1
Other2
Other3
Other1 Text
Other2 Text
Other3 Text
Weight Loss Success
Weight Loss Behaviors
Sweet Eater
Sweet Eater Explained
Sweet Eater Frequency
Carb Eater
Carb Eater Explained
Carb Eater Frequency
Fast Food Eater
Fast Food Eater Explained
Fast Food Eater Frequency
Snack Eater
Snack Eater Explained
Snack Eater Frequency
Snack Eater Habit
Snack Eater Boredom
Binge Eater
Binge Eater Frequency
Soda
Diet Soda
Juice
Crystal Lite
Sports Drink
Energy Drinks
Coffee
Decaf Coffee
Coffee Drink
Cardiac History
Cardiac History Other
Endocrine History
Endocrine History Other
Pulmonary History
Pulmonary History Other
Urinary History
Urinary History Other
Psychological History
Psychological History Other
GYN History
GYN History Other
Gastrointestinal History
Gastrointestinal History Other
Hematological History
Hematological History Other
Neurological History
Neurological History Other
Musculoskeletal History
Musculoskeletal History Other
ESS Sitting Reading
ESS Watching TV
ESS Sitting Inactive
ESS Car Passenger
ESS Lying Down
ESS Sitting Talking
ESS Sitting Quietly
ESS Car Traffic
Other History
Other History Other
Blood Transfusions
Allergies
Allergies Description
Social/Family History
Social/Family History Other
Beer
Wine
Other Liquor
Alcohol Abuse History
Past Drinker Age
Cigarettes
Cigars
Vaping
Chewable Tabacco
Past Smoker Age
Drugs Or Marijuana
Drugs Or Marijuana Description
Drug Abuse History
Past Drug Abuse Age
Regular Exercise
Physical Exercise Restrictions
Physical Exercise Restrictions Reason
Support System
Abuse Exposure
Weight Loss Primary Goals
Weight Loss Fears Concerns
Additional Information
Support System Other
SleepScore
Snore
Tired
Obstruction
Pressure
BMI
BangAge
Neck
BangGender
Past Diets Other
Insurance Type Other
RecordID
FormStatus
PriorSurgeries
PriorSurgeriesExplained
DietsTried
WeightLossMeds
WeightLossEncouragement
ProgramInterest
FunctionalHealthStatus
Attachments

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Bariatric Intake Questionnaire

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