Get the free Bariatric Surgery Evaluation Form - UPMC.com

For Office Use Only Date Received BMI Division of Minimally Invasive Bariatric and General Surgery Anita Corollas, MD Giselle Haman, MD Carol McCloskey, MD Ramesh Samantha, MD INITIAL EVALUATION FORM

How to fill out bariatric surgery evaluation form

Advice on how to fill out a bariatric surgery evaluation form:

1. Begin by carefully reading through the evaluation form instructions. Make sure you understand each section and the information being requested.
2. Gather all relevant medical records, including previous surgeries, current medications, and any pre-existing conditions. These documents will provide important information for completing the form accurately.
3. Start by filling out personal information such as your name, date of birth, and contact details. Double-check for any spelling errors or inaccuracies.
4. The next section will likely ask about your weight history. Include details such as your highest weight, current weight, and any attempts or methods you've used to lose weight in the past.
5. Be prepared to answer questions about your current physical health. This may entail providing information on any chronic illnesses, allergies, or conditions you may have.
6. The evaluation form will likely inquire about your mental and emotional well-being. It may ask about any history of depression, anxiety, or other mental health disorders. Answer these questions honestly and thoroughly.
7. The next section might focus on your eating habits and lifestyle. It may ask about your typical diet, exercise routines, and any substance use like smoking or alcohol consumption.
8. There might be a section dedicated to evaluating your knowledge and understanding of the risks, benefits, and requirements associated with bariatric surgery. Take your time to read the questions carefully and answer them truthfully.
9. If the form includes a space for additional comments or concerns, feel free to elaborate on any aspects that you believe deserve more attention or explanation.
10. Finally, review the filled-out form, ensuring all the information provided is accurate and complete. Sign and date it as required.

Who needs a bariatric surgery evaluation form?

1. People who are considering or have been recommended for bariatric surgery.
2. Individuals who have struggled with weight issues and are seeking solutions to improve their health and quality of life.
3. Patients who have attended informational sessions or consultations regarding bariatric surgery and wish to proceed with the evaluation process to determine their eligibility.
4. Medical professionals and healthcare teams involved in assessing the suitability of a patient for bariatric surgery and monitoring their pre-operative health status.
5. Insurance companies or healthcare providers who require a comprehensive evaluation before approving bariatric surgery coverage or benefits.

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What is bariatric surgery evaluation form?

The bariatric surgery evaluation form is a document used to assess a patient's candidacy for weight loss surgery.

Who is required to file bariatric surgery evaluation form?

Patients who are considering undergoing bariatric surgery are required to fill out the evaluation form.

How to fill out bariatric surgery evaluation form?

To fill out the bariatric surgery evaluation form, patients need to provide detailed information about their medical history, current health status, and reasons for seeking weight loss surgery.

What is the purpose of bariatric surgery evaluation form?

The purpose of the bariatric surgery evaluation form is to help healthcare providers determine if a patient is a suitable candidate for weight loss surgery and to assess potential risks.

What information must be reported on bariatric surgery evaluation form?

The bariatric surgery evaluation form typically requires information such as BMI, medical conditions, previous weight loss attempts, and psychological evaluations.