BARIATRIC SPECIFIC : MEDICAL/SURGICAL HISTORY:
**NOTE: IT IS VERY IMPORTANT THAT YOU LIST ALL PRIOR ATTEMPTS AT WEIGHT LOSS IN THE APPROPRIATE SECTIONS BELOW .
** Insurance will look at these when determining if you meet criteria for coverage **
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WEIGHT/DIET HISTORY: (ALL fields are Mandatory):
Name *
CURRENT HEIGHT (FT / INCH):  *
EXAMPLE: 6FT 2INCH
CURRENT WEIGHT (LBS) *
WHAT WAS YOUR HIGHEST WEIGHT EVER? (LBS)
WHAT WAS YOUR APPROXIMATE WEIGHT IN POUNDS (5 Years Ago): *
WHAT WAS YOUR APPROXIMATE WEIGHT IN POUNDS (10 Years Ago): *
When did you first have issues with your weight? (YEARS) *
Was your weight gain? *
Which of the following are you interested in? (Please select): *
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