Exit

1.

 
 100% of survey complete.
Thank you for considering our practice. Once you hit DONE at the end of the questionnaire, your application will be submitted to us electronically and in a HIPAA compliant fashion. If you have not heard back from us within 1-2 business days, please contact us at (805) 379-9796. If you prefer, a PDF of this questionnaire can be emailed or mailed to you. 

Question Title

1. Your full name

Question Title

2. Your date of birth?

Question Title

3. Mailing address:

Question Title

4. Best telephone number(s) to reach you and leave private messages.

Question Title

5. Email address(es) where you can receive personal private emails.

Question Title

6. Emergency contact information:

Question Title

7. What is your insurance? Please include as much information as possible including policy number.

Question Title

8. If possible, please upload a copy of your insurance card(s), front and back. Supported formats are PDF, JPG,JPEG,GIF, PNG,DOC,DOCX

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

Question Title

9. Primary care MD: Please include full name, address, phone and fax, and if known, email address

Question Title

10. Please provide the name, specialty, and complete contact information for your other doctors & healthcare providers

Question Title

11. How long have you been contemplating bariatric surgery?

Question Title

12. How have you researched about bariatric surgery?

Question Title

13. A pre-consultation information seminar attendance is highly encouraged -and sometimes mandatory- in bariatric surgery. Please indicate which one of the following applies to you?

Question Title

14. How did you hear about University Bariatrics?

Question Title

15. If you were referred to us through a hospital website, advertising campaign, or doctor referral line: please indicate which one.

Question Title

16. At what age did you first start dieting?

Question Title

17. Which of the following diets have you been on in the past. Please mark all that apply.

Question Title

18. What was the most successful weight loss program ever and how much weight did you lose. Please indicate approximate year or age.

Question Title

19. Are you a sweet eater? If so, please indicate type, amount, and freqency on a weekly basis

Question Title

20. Are you a carb eater? If so, please indicate type, amount, and freqency on a weekly basis

Question Title

21. Are you a fast-food eater? If so, please indicate type, amount, and freqency on a weekly basis

Question Title

22. On a typical day, how much soda or other non-alcoholic beverages do you consume daily?

  None 8 oz or less(one can) 16-24 oz (2-3 cans) 36-64 oz More than 64oz
Soda
Diet Soda
Juice
Crystal Lite or similar artificially sweetened drinks
Sports drinks (Gatorade)
Energy drinks (RedBull)
Coffee
Decafeinated coffee
Coffee drinks (eg latte, capuccino, machiatto, frappucino, etc)

Question Title

23. Which one of the following applies to you:

Question Title

24. Please indicate your height, weight, and BMI (if known)

Question Title

25. What are your primary goals and reasons to pursue weight loss surgery?

Question Title

26. Cardiac history: Please mark all that apply.

Question Title

27. Pulmonary History: Please mark all that apply.

Question Title

Please calculate your sleep score and document in the next question. Score above 9 may indicate sleep apnea.

Please calculate your sleep score and document in the next question. Score above 9 may indicate sleep apnea.

Question Title

28. What was your Epworth Sleepiness Score from chart above?

Question Title

29. Gastrointestinal history: Please mark all that apply.

Question Title

30. Endocrine history: Please mark all that apply.

Question Title

31. Hematological history: Please mark all that apply

Question Title

32. Urinary history: Please mark all that apply

Question Title

33. GYN history (women only): Please mark all that apply

Question Title

34. Musculoskeletal history: Please mark all that apply

Question Title

35. Neurological history: Please mark all that apply

Question Title

36. Psychological history: Please mark all that apply.

Question Title

37. Other history:

Question Title

38. Have you had previous weight loss surgery such as gastric bypass, adjustable bands, gastroplasty etc?

Question Title

39. If you have had previous weight loss surgery, please indicate which one(s).

Question Title

40. Other past medical or surgical history or hospitalizations not mentioned above. Please include approximate dates and write on SEPARATE lines for each event.

Question Title

41. If you have had general anesthesia before, i.e. have been put to complete sleep for a surgical procedure, please check the appropriate box.

Question Title

42. COMPLETE list of prescription medications.

Question Title

43. COMPLETE list of non-prescription, over-the-counter, or herbal medications and supplements.

Question Title

44. Drug or other chemical allergies

Question Title

45. Family history: Please mark all that apply.

Question Title

46. Current alcohol history:

  none Less than five drinks per week More than 6 drinks per week
Beer
Wine
Other liquor

Question Title

47. Current tobacco/nicotine history:

  No Yes
Cigarettes
Cigar
Chewable tobacco
E-cigarrettes
Pipe
Hookah or other modalities

Question Title

48. I currently use drugs including medical marijuana. 

Question Title

49. What is your current occupation

Question Title

50. Marital status

Question Title

51. What is your highest education level?

Question Title

52. Having a support system before and after surgery is vital to successful and safe outcomes.

Question Title

53. This application has been filled out by myself or with the help of someone else under my guidance. In either case, by writing my name below, I attest that all the information is accurate to the best of my abilities.

T