Bariatric Surgery Intake Form Please enable JavaScript in your browser to complete this form.Name *FirstLastStreet Address *City *State *select stateAlabamaArizonaArkansasColoradoConnecticutDelawareDistrict of ColumbiaGeorgiaIdahoIllinoisIndianaKansasKentuckyMaineMarylandNebraskaNevadaNew HamshireNew JerseyNorth CarolinaOhioOklahomaPennsylvaniaTennesseeTexasUtahVirginiaWashingtonWisconsinIf your state is not listed here, I am unable to complete your evaluation.Phone Number *Name of Emergency Contact *FirstLastWho should I contact in the event of an emergency?Emergency Contact Phone Number *Surgery Type *Sleeve Gastrectomy (Gastric Sleeve)Roux-en-Y Gastric BypassAdjustable Gastric BandDuodenal SwitchUndecidedWhich surgery are you considering?Surgeon's Name *FirstLastWho is requesting the pre-surgical psychological evaluation? If you do not know your doctor’s first name you can put “Doctor” in the first name field.Name of Practice *Name of your doctor’s officeSurgeon's Office Number *Surgeon's Fax Number *Current Weight *Highest Weight *Goal Weight *Past Weight Loss Methods *DietingExerciseLiquid dietMedically supervised dietDiet pillsLaxativesPurging after eatingFastingCalorie countingDieticianPhysical TrainerOtherAdditional DetailsPlease provide additional details about prior weight loss attempts and why you think they were ultimately unsuccessful. Past Mental Health Treatment *NoneIndividual therapyFamily therapyMedication by psychiatristIntensive outpatient programPsychiatric day programMarriage counselingEAP CounselingMedication by non-psychiatristInpatient hospitalization(s)Substance abuse treatmentOtherCurrent Mental Health TreatmentNoneIndividual therapyFamily therapyMedication by psychiatristIntensive outpatient programPsychiatric day programMarriage counselingEAP CounselingMedication by non-psychiatristInpatient hospitalization(s)Substance abuse treatmentOtherCurrent level of stress Selected Value: 0 Please move the slider to indicate your current level of stress (0 = no stress, 10 = completely stressed)Current level of depression Selected Value: 0 Please move the slider to indicate your current level of depression (0 = no depression, 10 = worst depression)Current level of anxiety Selected Value: 0 Please move the slider to indicate your current level of anxiety (0 = no anxiety, 10 = Worst anxiety)Submit