Bariatric Patient Questionnaire

Atomic Shrink Psychology, Inc. · Pre-Surgical Psychological Evaluation

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.

Patient Information

Full Legal Name *

Date of Birth *

Email Address *

Phone Number *

Current Address

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. *

Attestation & Signature

I attest that everything I have stated above is true and accurate to the best of my knowledge. *

By typing my full legal name below, I confirm the completeness and truthfulness of all responses in this questionnaire.

Date of Signature *

How to submit

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It will be addressed to drstory@atomicshrink.com.
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