Important Instructions
Complete every question in full. Do not leave any item blank.
Short or one-word answers are not accepted. Each response must be thorough, specific, and fully described (include dates, durations, examples, reasoning, and context).
If a question has two parts, both parts must be answered completely.
Insufficient detail will result in the questionnaire being returned before review or scheduling can proceed.
I. Purpose of Evaluation
1. Describe your understanding of the bariatric procedure you are considering, including what the surgery involves, its goals, and its possible risks or limitations. *
2. Explain your main reasons for pursuing bariatric surgery, including medical, emotional, and social motivations. *
3. Describe how long you have been considering weight-loss surgery, what influenced your decision, and why this timing feels appropriate now. *
II. Medical & Surgical History
1. Provide your current weight, height, and BMI, and describe how these have changed over time. *
2. Describe all medical conditions related to weight (e.g., hypertension, diabetes, sleep apnea, GERD, osteoarthritis) and how they affect your daily life. *
3. List all previous weight-loss attempts (diets, medications, exercise programs, support groups, or surgeries) and explain which were effective or ineffective and why. *
4. Describe any major weight fluctuations you have experienced in adulthood, including your highest and lowest weights, ages or years, and causes for each change. *
5. List all previous surgeries, describe recovery processes, emotional adjustment, and any complications you experienced. *
III. Psychiatric & Mental Health History
1. Describe any mental health diagnoses you have received (e.g., depression, anxiety, PTSD, bipolar disorder, eating disorder) and how they relate to your weight or eating behavior. *
2. Provide details of all therapy or psychiatric treatment you have received, including type, duration, and effectiveness. *
3. Describe any hospitalizations for psychiatric issues or crises, including the reason, treatment provided, and outcome. *
4. List all psychiatric medications you currently take, their purpose, and how they affect your daily functioning. *
5. Explain any past or current suicidal thoughts, self-harm, or violent thoughts, including what actions or treatments were taken. *
IV. Emotional Regulation & Coping Skills
1. Describe how you typically manage stress, frustration, or emotional distress and how effective your methods are. *
2. Explain any patterns of emotional, stress, or binge eating, including what triggers them and how often they occur. *
3. Describe any compulsive eating or exercise habits, calorie restriction, or food-related obsessions and how they impact your life. *
4. Explain whether you experience mood swings, impulsive behavior, or difficulty controlling emotions, and how you handle these situations. *
5. Describe any experiences of eating in secret or feeling guilt or shame about food, and how you manage those emotions. *
6. Explain how you cope with boredom, loneliness, sadness, or anxiety without using food. *
V. Substance Use & Addiction History
1. Provide full details about your current use of tobacco, alcohol, or recreational drugs, including frequency, quantity, and last use. *
2. Describe any past history of substance abuse, including food addiction, and explain how it affected your health or lifestyle. *
3. Explain any substance-use treatment you have received (rehab, counseling, outpatient care), what you learned, and how you maintain recovery or control today. *
4. List all prescription or over-the-counter appetite suppressants, stimulants, or diet pills you have used, including purpose, frequency, and results. *
VI. Cognitive Function & Decision-Making Capacity
1. Describe any history of head injuries, concussions, or neurological issues and how they have affected your memory or thinking. *
2. Explain any difficulties with attention, focus, or decision-making, and describe how you manage them. *
3. Describe your understanding of the risks, benefits, and long-term responsibilities of bariatric surgery. *
4. Explain how you have researched and prepared for post-surgical dietary, behavioral, and lifestyle changes. *
5. Describe how you plan to adhere to lifelong follow-up care and behavioral modifications after surgery. *
VII. Social & Family Support System
1. Describe your relationship status and explain how your partner or household members feel about your decision to have surgery. *
2. Explain how your children, dependents, or close family members feel about your decision and how it may affect family dynamics. *
3. Describe the strength of your social support system, including who you rely on for encouragement and accountability. *
4. Explain how family or friends have responded to your weight-loss efforts in the past and how that affects you now. *
5. Describe any history of emotional, physical, or sexual abuse and explain whether you currently feel safe in your environment. *
VIII. Lifestyle & Behavioral Readiness
1. Describe your current eating habits, including meal patterns, portion sizes, and timing. *
2. Explain your current exercise or physical activity routine, including how often you engage and what activities you perform. *
3. Describe how you plan to follow strict post-operative dietary guidelines and maintain them long-term. *
4. Explain any pre-surgical nutrition or counseling sessions you have attended and what you learned from them. *
5. Describe the challenges you anticipate after surgery and explain how you plan to manage each one effectively. *
IX. Risk Factors for Post-Surgical Complications
1. Explain how you respond when situations do not go as expected and provide examples of coping strategies you use. *
2. Describe any patterns of emotional or binge eating and how you currently manage them. *
3. Explain whether depression, anxiety, or other emotional issues worsen during major life changes and how you manage that risk. *
4. Describe any past challenges following medical advice or treatment plans and what changes you have made to improve compliance. *
5. Explain in detail how you intend to maintain regular follow-up with your medical team and adhere to long-term care requirements. *
6. Describe any fears or concerns you have about surgery or the post-operative period and how you plan to address them. *
X. Goal Setting & Prognosis
1. Describe your short-term and long-term goals after surgery and how you will measure progress toward each. *
2. Explain how you define success in your weight-loss journey beyond numbers on a scale. *
3. Describe the non-weight-related benefits you hope to gain (e.g., improved mobility, confidence, energy). *
4. Explain how you will evaluate progress using emotional, behavioral, and physical indicators. *
5. Describe what resources, supports, or programs will help you maintain success after surgery. *
Final Considerations & Patient Understanding
1. Explain any questions or concerns you have about the psychological or emotional aspects of bariatric surgery. *
2. Describe what you believe will be the most challenging part of your post-surgical adjustment and how you intend to handle it. *
3. Explain how you know you are mentally and emotionally ready to commit to the changes required for long-term success. *
How to submit
Click the green button below.
Your email program will open with the completed questionnaire already filled in.
It will be addressed to drstory@atomicshrink.com .
You must still click Send inside your email program to finish.
✉ Open Email & Submit