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Central Iowa Psychological Services Compassionate, Whole Person Care, Where You Matter Gastric Bypass PreSurgical Psychological Evaluation Intake Form Please complete the following history form in
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How to fill out gastric bypass intake form
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Start by providing your personal information, such as your name, date of birth, and contact details.
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Next, fill in your medical history. This includes any pre-existing conditions, previous surgeries, and medications you are currently taking. Be honest and provide as much detail as possible.
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Provide information about your weight and any previous attempts at weight loss. This helps the healthcare provider understand your history and potential challenges.
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Answer questions about your eating habits, including your typical diet, portion sizes, and any emotional or binge eating behaviors. Be open and honest, as this information is crucial for developing an effective treatment plan.
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Fill out the form regarding any previous attempts at weight loss, such as diets, exercise programs, or weight loss medications. Include details about your success or challenges you faced.
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Discuss your expectations and goals for gastric bypass surgery. Briefly mention what you hope to achieve through the procedure, whether it is improved health, increased mobility, or overall weight loss.
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Medical professionals responsible for administering and monitoring gastric bypass surgery.
Note: It is important to consult with a healthcare professional and follow their guidance when filling out any medical forms or considering gastric bypass surgery.
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