Metabolic and Bariatric Surgery - New Patient Questionnaire

Welcome to our practice! We are excited to learn more about you and how we can help you achieve your weight loss goals. Please answer the following questions as accurately as possible. Your surgical team will use your answers to help guide your treatment.

Please indicate current or prior use of each of the following substances.



Tobacco products




Other drugs

Gastroesophageal Reflux Disease Questionnaire (GERD-Q)

Please select the option that corresponds to the frequency of symptoms you experience in an average 7 day period. The numbers are added together to calculate your total score

STOP BANG Questionnaire for obstructive sleep apnea

Your BMI and neck circumference will be measured during your clinic visit. Please answer the remaining questions to the best of your knowledge. If you have already been diagnosed with obstructive sleep apnea and are using a CPAP machine at home, you may skip this portion of the questionnaire.