WLS Patient Info Form

Please note, all fields are required. If a field does not pertain to you, please type "N/A" or "Not applicable".

Personal Info

Name*

First Middle Initial Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Email*

Phone Number*

Date of Birth*

MM slash DD slash YYYY

Age*

Please enter a number from 0 to 105.

Marital Status*

Married

Single

Widowed

Divorced

Gender*

Male

Female

Height

(Enter feet + inches; example: 5' 6")

Weight

(Enter pounds; example: 200 lbs)

Employer*

Occupation*

Insurance Card

Please upload a copy of your insurance card. Please include the front and back of the card.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 2.

Medical Info

Family Doctor*

Referring Doctor*

Have you ever seen a cardiologist?*

Yes

Date & Provider*

Date

Provider

Have you ever seen a pulmonologist?*

Yes

Date & Provider*

Date

Provider

Preferred Pharmacy*

Drug Allergies*

Are you allergic to latex?*

Yes

What Medications are you currently taking?*

Please include ALL over the counter medications, vitamins, blood thinners (includes aspirin), and any herbal supplements.

Medication

Dose

Frequency

Please list all operations and the date.*

Operation

Date

What conditions do you have now?*

Atrial Fib

Heart Attack

High Blood Pressure

Pulmonary Embolism

Stroke

GERD/Reflux

Ulcer

Pancreatitis

Stress Urinary Incontinence

Diabetes

Gout

High Cholesterol

Pre-Diabetes

Thyroid Trouble

Mental Health

Asthma

Emphysema/COPD

Sleep Apnea

PCOS

HIV

MRSA

VRE

NONE

Check any device or implants you have ever had or currently use.*

Cardiac Stents

Pacemaker

CPAP

BIPAP

None

What year did you have your stent placed?*

Other hospitalizations and medical problems:*

Have you ever had a colonoscopy?*

Yes

Date & Provider*

Date

Provider

Have you ever had an EGD?*

Yes

Date & Provider*

Date

Provider

Do you smoke?*

Yes

How much do you smoke?*

Do you chew?*

Yes

How much do you chew?*

Do you use and e-cig/vaporizer?*

Yes, with nicotine

Yes, without nicotine

How much do you vape?*

Do you use drink alcohol?*

Yes

How many drinks per week?*

Do you use illegal drugs?*

Yes

Which drugs, and how often?*

Do you smoke marijuana?*

Yes

How often do you use marijuana*

Family History

Is your mother alive?*

Yes

Mother's Age*

Please enter a number from 18 to 105.

Mother's Age & Cause of Death*

Is your father alive?*

Yes

Father's Age

Please enter a number from 18 to 105.

Father's Age & Cause of Death*

How many children do you have?*

Please enter a number from 0 to 20.

What are their ages?*

IIlnesses that occur in your family*

Cancer of the Bowel

Cancer of the Breast

Cancer of the Lung

Cancer of the Skin

Cancer of the Ovary

Cancer of the Uterus

Melanoma

Bleeding

Diabetes

High Blood Pressure

Severe of Young Heart Problens

Malignant Hyperthermia with Anesthesia

Stroke

Other cancers

None

Other Cancers*

Please list mental health condtions*

Diet History*

Please list any diet attempts you've made in the past 10 years

Have you ever utilized any of the following?*

Support Groups/Counseling

Exercise Programs

Prescription Weight Loss Medications

List Prescription Loss Medications*

Food & Diet Info

Food Intolerances*

What aspects of losing weight do you have the most trouble with?*

What is your highest weight as an adult?*

What is your goal weight?*

What is your lowest weight as an adult?*

At what age did you begin to struggle with your weight?*

Please list all physical barriers that limit your ability to be physical active.*

(ex: joint pain, shortness of breath, fatigue, etc.). Please be specific.

Food & Diet Info

How many meals do you eat per day?*

How many snacks?*

Do you struggle with the grazing** behavior?*

**Grazing is defined as snacking frequently.

How often do you eat out per week?*

How many minutes does it take to consume a meal?*

Who does the grocery shopping?*

Who prepares your meals?*

Has binge eating ever been an issue for you?*

Has purging* ever been an issue for you?*

*Purging is defined as emptying one’s stomach or bowels by inducing vomiting or using laxatives.

Yes

If yes, when was the last incident?*

How many carbonated beverages do you consume per day?*

Type of carbonated beverage

Number consumed per day

How many caffeinated beverages do you consume per day?*

Type of caffeinated beverage

Number consumed per day

Please list the items you will not eat or drink.*

Approximately how many times a day do you consume the following foods?*

Meats

Dairy

Bread, Pasta, Rice, etc

Fruit

Veggies

Sweets

High Fat Items

Any other food related comments?

Goals you would like to reach by having weight-loss surgery?*

With whom have you shared your decision to have surgery?*

Comments/Concerns you may have:

WLS Patient Info Form

Notice

Weight Loss Surgery Patient Information Form

Personal Info

Medical Info

Family History

Food & Diet Info

Food & Diet Info