Instructions for Completion of
Bariatric Psychological Questionnaire

You have been referred for a bariatric psychological evaluation as part of the preoperative clearance process. Before completing any portion of the attached Bariatric Psychological Questionnaire, you are required to read this document in its entirety and sign the attestation below.

The questionnaire is a required component of the psychological evaluation and is used to assess your understanding of the bariatric procedure, your readiness for surgery, and your capacity to comply with long term postoperative medical and behavioral requirements. All questions must be answered completely. No sections may be left blank.

Short or minimal responses are not accepted. One word answers, vague statements, generalized responses, or statements lacking detail are insufficient and will delay the evaluation process. You are required to provide detailed, specific, and concrete information for every question.

All information you provide must be time anchored and behaviorally specific. This includes dates, durations, frequencies, examples, and outcomes where applicable. You are specifically required to list and describe all prior methods of dieting or weight loss you have attempted. This includes, but is not limited to, named diets, physician supervised programs, commercial programs, medications, exercise based regimens, self directed dieting efforts, and any other weight loss strategies used in the past. For each method, you must indicate the timeframe, degree of weight loss achieved, duration of maintenance, and reason the method was discontinued.

The bariatric psychological evaluation is a formal clinical assessment conducted for surgical clearance purposes. It is not an appointment for ongoing psychological treatment. The accuracy, completeness, and specificity of the information you provide directly impact the validity of the evaluation and the determination rendered.

If you are unable to demonstrate adequate understanding of the bariatric procedure, postoperative requirements, long term lifestyle changes, or follow up care expectations at the time of evaluation, psychological clearance may be deferred. In such cases, a non clearance determination may be issued with the understanding that, once additional education is provided by the surgical team, the psychological evaluation may be repeated.

Failure to disclose relevant information, providing inaccurate information, or submitting incomplete responses may result in delays or deferral of psychological clearance.