Health Questionnaire

This information is needed to qualify you for weight loss surgery

This information is needed to qualify you for weight loss surgery and to provide a safe surgery if you decide to schedule surgery with our team.
Please review each medical condition, if you have a history of any of the following symptoms or conditions please specify.

This information is needed to provide a safe surgery if you decide to schedule surgery with our team.

Indicate which of these items you have used in the last 30 days. Skip this section if it does not apply.

• alcohol products
• caffeine products
• nicotine products
• marijuana products
• hormones (including birth control)
• aspirin products

This is not a required field:
Mailing address allows our t eam to send you educational resources, swag, and allows us to plan for local events in your local area.

These questions are critical for our surgeons to decide what weight loss surgery option is best for you. Filling out this form, there is no obligation. This form is only to help guide you in the right direction for your journey. Please fill this form out accurately and in its entirety.

SELF DECLARATION

The information I provided in this health questionnaire is truthful, honest, and accurate. I understand that if I fail to tell the truth, there can be serious consequences including, but not limited to poor results, complications and my physical well-being.