Skip to main content

ALERT BAR

  Bariatric Services

Weight Loss Medical History Questionnaire


  • 1 Step 1
  • 2 Step 2
  • 3 Step 3
  • 4 Step 4
  • 5 Step 5
  • 6 Step 6
  • 7 Step 7
  • 8 Step 8
  • 9 Step 9
  • 10 Step 10
Please complete this questionnaire. Do not leave any questions blank. If the question does not apply, please answer with “NA.”
Patient Information

To print, fill out, and mail or scan the questionnaire to us, please download the form.

Gender

Insurance Information
Weight Loss Interest
Interested in:
Have you scheduled to attend an informational seminar?
Previous step
Previous Attempts at Weight Loss

Weight-Loss Medication History 
Please indicate if you have taken any of the following medications to lose weight. Indicate the dates, duration, whether it was medically supervised and your weight loss amount.

Previous step
Previous Attempts at Weight Loss - Continued

Non-Dietary Therapies
Please indicate if you have tried any of the following weight loss therapies. Indicate the dates, duration, whether it was medically supervised and your weight loss amount.


Previous Weight Loss Surgery
Previous Evaluation by a Bariatric Surgeon

*Please bring your bariatric health records with you to your first appointment.

Previous step
Obesity Related Medical History

Do you, or have you ever had any of the following illnesses symptoms?

Heart Disease
Chest Pain
Myocardial Infarction (Heart Attack)
Coronary bypass surgery
Palpitations (abnormal heart beat)
Heart valve problems
Pulmonary hypertension
Congestive heart failure
Stroke
High Blood Pressure
Elevated Cholesterol or Triglycerides

Diabetes Mellitus
Juvenile onset
Gestational (pregnancy)
Diet controlled
Oral medications
Insulin
Thyroid Disease
Kidney Disease

Sleep Apnea
Do you use a CPAP or BiPaP machine?
Has someone told you that you stopped breathing while you were sleeping?
Have you had corrective surgery?

Sleep difficulties:

Snoring
Awakenings at night
Daytime drowsiness
Observed apnea spells
Morning headaches

Reflux/GERD/Heartburn/Esophagitis/Hiatal Hernia
Asthma
COPD

Continued in the Next Step

Previous step
Obesity Related Medical History - Continued

Do you, or have you ever had any of the following illnesses symptoms?

Pseudotumor Cerebri (Idiopathic Intracranial Hypertension)

Headaches
Do you take prescription medications
Do you take over the counter medications
Seizures

Arthritis or Pain in the Ankles/Knees/Hips
Limits the ability to walk or exercise
Do you take prescription medications
Do you take over the counter medications

Cancer

If yes, please include type, year of diagnosis, and remission status.


Women:

Are you, or could you be pregnant?
Are you planning on becoming pregnant within 6 months?
Polycystic Ovarian Syndrome (PCOS)
Abnormal or Irregular Uterine Bleeding
Venous Stasis
Leg or ankle swelling/edema
Leg ulceration
Leg skin color changes or thickening

Deep Vein Thrombosis (Blood clots in leg)

Pulmonary embolism

Back/Hip/Knee pain/Sciatica
Limits the ability to walk or exercise
Do you use prescription medication?
Do you use over the counter medications?

Abdominal Wall Hernia
Number of hernia repairs
Incisional
Umbilical (belly button)
Hernia currently present

Urinary Incontinence (leakage of urine)
With coughing/sneezing/straining

Liver Disease
Have you ever had hepatitis?
Have you ever had an organ transplant?

Continued in the Next Step

Previous step
Obesity Related Medical History - Continued

Do you, or have you ever had any of the following illnesses symptoms?

Have you ever abused intravenous drugs?
Do you use tobacco?

Please indicate amount and frequency

Do you use alcohol?

Please indicate amount and frequency

Do you use non-legal drugs?

Please indicate type and frequency

Have you ever been treated for an eating disorder (anorexia, bulimia)?
Have you ever eaten a large amount of food rapidly and felt this eating incident was excessive and out of control (aside from holiday meals)?
Have you ever been treated for any of the following?
Are you currently in treatment or any of the above?
Have you ever been hospitalized for mental illness?
Have you ever had suicidal ideations or suicidal attempts?

Are you able to walk without assistance?
Has a physician or medical provider ever told you not to exercise?
Do you require supplemental oxygen?

Continued in the Next Step

Previous step
Medical and Surgical History / Preventative Screenings

Past Medical History

Past Surgical History

Please list all surgical procedures or operations:





Preventative Health Screening

Women: 

Mammogram
Pap smear
Colonoscopy
Previous step
Medications

Please list all medications you currently use, including “over the counter” medications, herbal remedies, and dietary supplements. Please do not say “refer to my chart” or “too many to list.” (Please bring list or medications to visits)











Previous step
Allergies
Do you have allergies to any medications?

If yes, please list medications and reactions (e.g., rash, breathing difficulty, shock, etc.)







Do you have any Food Allergies

If so, are you allergic to:

Cocoa
Milk Protein
Corn
Soy
Eggs

Are you sensitive or do you have a problem with:

Monosodium glutamate (MSG)
Lactose

UTMB Health's Center for Obesity and Metabolic Surgery accepts private insurance, self-pay, Medicare, and Medicaid. However, some policies have exclusions for weight loss surgery. You may want to call your insurance to determine coverage and/or exclusions for weight loss surgery.