Leading the field in weight loss surgery

Complete Your Bariatric Questionnaire Below:

Welcome to your Bariatric Questionnaire

Name
Email
Date
How long have you considered Bariatric Surgery?
How did you first learn of Bariatric Surgery?
Do you know other patients who have undergone Bariatric Surgery?
If yes, was the surgery successful?
Are your friends/family supportive of your decision to pursue Bariatric Surgery?
Have you tried dieting in the past?
How much weight have you lost while dieting?
How many diets have you tried in the past year?
Have you ever tried the following for weight loss?
What brand of diet pills did you try?
How much did you lose with this type of diet pill?
How long did you use this diet pill?
What is your maximal weight reached in your lifetime?
What is your lowest weight achieved in the past 10 years?
Have you ever meditated before?
If yes, how often would you say you meditate
If no, are you open to learning how to meditate?
Have you ever heard of Mindful eating?
Do you feel there is a connection between how you feel and your thoughts and actions?
Do you consider yourself to be an emotional eater?
What do you feel is the main reason that you are overweight?
What is your personal goal weight with surgery?
How many lbs?
What is your main reason for trying to lose weight?
Do you have any of the following medical problems?
Please check all that apply:
Have you ever had surgery before?
Please list operations below
Family History (Medical Conditions in family members)
Do you smoke?
If yes, how many packs per day? (smoking)
How many alcoholic drinks do you drink?
Please check which applies:
Medication list:
Symptoms (circle all that apply)
Other symptoms not mentioned above:
Allergies:
Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?
Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
Do you have or are being treated for High Blood Pressure?
Body Mass Index more than 35 kg/m2?
Age older than 50 year old?
Neck size large? (Measured around Adams apple) For male, is your shirt collar 17 inches/43 cm or larger? For female, is your shirt collar 16 inches/41 cm or larger?
Gender = Male

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Napa, CA Office

1300 Main St #200
Napa, CA 94559

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Novato, CA OFFICE

165 Rowland Way #200
Novato, CA 94945

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