Bariatric Pre-Surgical Psychosocial Evaluation Questionnaire

Please complete this questionnaire before your scheduled bariatric psychosocial evaluation. Your responses will help guide our discussion and allow us to focus on the areas most relevant to your preparation for bariatric surgery.

There are no “right” or “wrong” answers. Please answer as openly and accurately as possible. Your responses are one part of the overall psychosocial evaluation and will be reviewed with you during your appointment.

Please allow enough time to complete the questionnaire thoughtfully. If you are unsure how to answer a question, provide the information you know and we can discuss it during your evaluation.

ABOUT YOU

Full Legal Name

Preferred Name

Date of Birth

Phone Number

Email Address

Current Address

City / State / ZIP

What is your current relationship status?

Single Married Partnered Separated Divorced Widowed Other

Who currently lives in your household?

Are you currently employed?

Yes, full-time Yes, part-time Self-employed Not currently employed Disabled/unable to work Retired Student Other

Occupation, if applicable

YOUR BARIATRIC PROGRAM

Name of bariatric surgeon

Bariatric program/medical group

What bariatric procedure are you considering?

Sleeve gastrectomy Gastric bypass Revision surgery Not yet determined Other

Have you previously had bariatric surgery?

No Yes

If yes, please provide the type of procedure and approximate date:

If you are seeking revision surgery, please briefly describe the reason for the revision:

Does your bariatric program have a specific form, letter, or requirements for your psychosocial evaluation?

Yes No I'm not sure

Upload bariatric program requirements (if applicable) If your bariatric program provided a form, letter, checklist, or other requirements for your psychosocial evaluation, please upload them here.

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Please upload a file

WEIGHT AND HEALTH HISTORY

Current weight

Height

Highest adult weight

Lowest adult weight

At approximately what age did you begin experiencing significant concerns with your weight?

Please describe previous attempts to lose weight (for example: structured diet programs, dietitian, exercise programs, medications, medically supervised weight loss, or other approaches).

What has made it difficult for you to maintain weight loss in the past?

Please describe anything else you would like me to know:

YOUR DECISION TO HAVE BARIATRIC SURGERY

How long have you been considering bariatric surgery?

Why are you interested in bariatric surgery at this point in your life?

What are the three most important things you hope will improve following surgery?

What are your expectations regarding weight loss following surgery?

What concerns, if any, do you have about having bariatric surgery?

How would you feel if you lost a significant amount of weight and improved your health, but did not reach your ideal or goal weight?

UNDERSTANDING BARIATRIC SURGERY

Please briefly describe your understanding of the procedure you are considering and how it will help with weight loss.

Do you understand that bariatric surgery is a tool and that maintaining long-term results generally requires ongoing behavioral and lifestyle changes?

Yes No Unsure

Is there anything about the surgery or postoperative requirements that you feel you do not yet understand?

EATING AND FOOD BEHAVIORS

How would you describe your current eating pattern on a typical day?

Have you ever felt that you could not stop eating or control what or how much you were eating?

Never Rarely Sometimes Often

If applicable, please describe:

Have you ever been diagnosed with or treated for an eating disorder?

No Yes

If yes, please explain:

What situations or emotions are most likely to affect your eating?

What changes have you already made to your eating habits in preparation for bariatric surgery?

MENTAL AND EMOTIONAL HEALTH

Have you ever been diagnosed with a mental-health condition?

No Yes

If yes, please list diagnosis/diagnoses and approximate dates if known:

Are you currently experiencing concerns related to your mental or emotional health?

No Yes

If yes, please describe:

Have you ever participated in counseling or psychotherapy?

No Yes, previously Yes, currently

If currently receiving treatment, please provide the provider name and how often you attend:

Have you ever received psychiatric treatment or medication management?

No Yes, previously Yes, currently

Are you currently taking medication for your mental health?

No Yes

If yes, please list medication(s):

Have you ever been hospitalized for a psychiatric or mental-health reason?

No Yes

If yes, please briefly explain:

ALCOHOL, NICOTINE AND OTHER SUBSTANCES

Do you currently drink alcohol?

Never Less than monthly 1–3 times per month 1–2 times per week 3 or more times per week

When you drink alcohol, approximately how many drinks do you typically have?

Have you ever felt that alcohol caused problems in your health, relationships, work, or other areas of your life?

No Yes

Have you ever received treatment or participated in a recovery program related to alcohol or substance use?

No Yes

If yes, please explain:

Do you currently use nicotine in any form, including cigarettes, vaping, cigars, or smokeless tobacco?

No Yes

If yes, please describe frequency:

Do you currently use cannabis?

No Yes

If yes, how often and in what form?

Do you currently use any recreational drugs or prescription medications in a manner other than prescribed?

No Yes

If yes, please explain:

Health Behaviors and Readiness for Change

How consistently do you attend scheduled medical appointments?

Almost always Usually Sometimes Rarely

How consistently do you take prescribed medications as directed?

Almost always Usually Sometimes Rarely I do not currently take prescription medication

Are you currently physically active?

Yes No Limited because of medical/physical concerns

If yes, please describe:

What behavioral or lifestyle changes have you already made in preparation for surgery?

What changes do you think will be the most difficult for you after surgery?

On a scale of 0–10, how confident are you in your ability to make the long-term changes required following bariatric surgery?

0 = Not at all confident | 10 = Extremely confident

Why did you choose that number?

SUPPORT AND RECOVERY

Who are the primary people supporting your decision to have bariatric surgery?

Does anyone important to you disagree with or have significant concerns about your decision?

No Yes

If yes, please explain:

Who will be available to help you immediately following surgery?

Do you have reliable transportation to surgery and follow-up appointments?

Yes No Unsure

Is your current housing stable?

Yes No Unsure

Are there financial, caregiving, work, relationship, transportation, or other circumstances that could make recovery or follow-up care difficult?

Yes No Unsure

If yes, please explain:

LIFE AFTER BARIATRIC SURGERY

What do you think will be the biggest adjustment for you after surgery?

How do you typically cope with stress or difficult emotions?

If food has been one of the ways you cope with stress or emotions, what other coping strategies could you use following surgery?

What personal strengths do you believe will help you succeed following surgery?

Are you willing to attend ongoing medical appointments and follow your bariatric team’s recommendations after surgery?

Yes No Unsure

What, if anything, do you think could interfere with your long-term success after bariatric surgery?

Is there anything else you would like me to know before we meet?

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