Initial Evaluation Form

Here are some reminders of steps you should complete before your appointment.

If your insurance company requires a referral to see a specialist, you must obtain one from your primary medical doctor and bring it with you on the day of your appointment.
You are responsible for knowing and understanding your own insurance plan. We will assist you in any way we can, but ultimately, you need to understand your benefits. Please do the following:
- Call your insurance company and verify that you have a benefit for weight loss surgery;
- Ask about co-pays, deductibles and using out of network benefits.
Fill out the Initial Evaluation Form below and bring it with you to your appointment. You will be delayed or rescheduled if it is not completed prior to the appointment.
Please fill it out as thoroughly as possible; some of the information is used to pre-certify the procedure with your insurance company.
Please feel free to contact us with any questions you may have in advance of your appointment, tel. # 609-585-2447.

Name:

Date of birth Enter as: xx/xx/xx

Age

Address

City

State

Zip

Home Phone Enter as: xxx-xxx-xxxx

Work or Cell Phone Enter as: xxx-xxx-xxxx

Preferred Number
Click for Home Click For Work or Cell

Occupation (optional)

Social Security Number (optional) Enter as: 123-45-6789

Email address

_____________________________________________________________________

INSURANCE INFORMATION

Primary Insurance

Secondary Insurance

Primary care Physician

Phone Number Enter as: xxx-xxx-xxxx

Address

City

State

Zip

_____________________________________________________________________

How were you referred here?

What was your primary reason for making this appointment?

Present weight?

Present height?

At what age did you begin to develop a weight problem?

At what age did you become morbidly obese?

PAST 5 YEAR WEIGHT HISTORY:

2009

2008

2007

2006

2005

2004

Please describe any events you believe may have contributed you your weight gain

_____________________________________________________________________

Weight Loss History

Has your primary care physician discussed weight loss options with you?
Click for YES Click For No

If yes, what treatment was recommended?
Lifestyle changes Medications Surgery

Have you ever been prescribed and taken prescription weight lose medication?
Click for YES Click For No

If yes, please list:

Name of medication	year started	how long	pounds lost	Lenght of time weight stayed off	how much weight regained

List all other diets, exercise programs and non-prescription medications you have tried.

Name of program	year started	how long	pounds lost	Lenght of time weight stayed off	how much weight regained

Approximately how much money have you spent on weight loss treatment?

Have you had previous surgery for weight loss?
Click for YES Click For No

If yes, what type

Are you currently on a diet for a medical reason?
Click for YES Click For No

If yes, please describe?

Have you ever had any nutritional counseling?
Click for YES Click For No

If yes, please describe?

List any allergies to food/medications

Other

Are you receiving any psychiatric/psychological services at this time?
Click for YES Click For No

If yes, by whom?

Are you currently being treated for depression?
Click for YES Click For No

If yes, by whom?

Have you been diagnosed with an eating disorder?
Click for YES Click For No

If yes, please describe?

Are you currently taking any medications (including supplements)?
Click for YES Click For No

Is yes, please list below

Medication	Dose	How often	Start date	prescription (yes or no)
				Click for YES Click For No
				Click for YES Click For No
				Click for YES Click For No
				Click for YES Click For No

Have you ever had any surgery
Click for YES Click For No

If yes, please list all surgical procedures with approximate date

_____________________________________________________________________

FAMILY HISTORY

Are you adopted
Click for YES Click For No

Current Lifestyle

Do you live alone
Click for YES Click For No

Do you have children
Click for YES Click For No

Do your children live at home
Click for YES Click For No

Does your family support your weight loss?
Click for YES Click For No

Do you smoke?
Click for YES Click For No

If yes, how many packs per day

Number of years

When did you quit

Do you drink alcohol
Click for YES Click For No

If yes, what type

How many drinks

How often

Do you currently use or have use illicit drugs
Click for YES Click For No

If yes, please describe drug, method and frequency of use

Do you exercise regularly
Click for YES Click For No

If yes, what type

How many times per week

How long each time

Do you feel sad most of the time
Click for YES Click For No

Has your appetite changed over the past six months
Click for YES Click For No

Has your interest in sex changed over the past six months
Click for YES Click For No

_____________________________________________________________________

For women

When was the first ay of your last menstrual period

Is your cycle regular
Click for YES Click For No

If no, please explain

Have you ever experience adnormal bleeding
Click for YES Click For No

If yes, please explain

How many times have you been pregnant

How many pregnancies have you delivered

What type of birth control do you use

Do you perform self breast exams
Click for YES Click For No

If yes, how often

When was your last Pap smear

When was your last mammogram

Are you planning to become pregnant
Click for YES Click For No

If yes, when