Weight Loss Medical History Questionnaire
Please complete this questionnaire. Do not leave any questions blank. If the question does not apply, please answer with “NA.”
To print, fill out, and mail or scan the questionnaire to us, please download the form.
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.