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All patients actively seeking weight-loss-surgery are required to bring this completed questionnaire to their initial consultation with our dietitian.
Do not leave sections blank, if none or not applicable indicate so in that section. Failure to bring questionnaire and forms completed to your consultation will result in the dietitians need to reschedule your consultation for a later date, as this paperwork is necessary to complete your assessment and enable the hospital to bill your insurance. All appointments are subject to availability. We need the full duration of your appointment to properly assess you as a surgical candidate so please bring paperwork completed to avoid additional out of pocket expenses, rescheduling and surgical delay.
There will be a $5.00 out-of-pocket fee for us to print the document at your appointment and you will be required to stay AFTER your consultation to complete and turn in before you leave the office. If new nutrition concerns are identified after we receive your questionnaire you may be asked to schedule a follow-up, during clinic hours, with our dietitians, at your own out-of-pocket expense. Follow-up services range from $35-$125.
This questionnaire takes approximately 20-30 minutes or more to complete. The document is available in two formats in MS Word Template format. This means you can download, type in your responses, save and fax to 443-490-5060 or email using our contact form on this site, no less than 48 business hours prior to your consultation. We also have a printable version and you can bring completed to your consultation.