Patient Name Date of Assessment Date of Birth Medical Record Number

Height (cm) Weight (kg) BMI Usual Weight (kg) Weight Change (kg) & Time Period

Type of Bariatric Surgery Planned Gastric Bypass Sleeve Gastrectomy Gastric Band Duodenal Switch Other

Relevant Medical History Allergies (Food/Medications) Current Medications

Diet History (Current Intake, Meal Pattern, Beverages) Food Intolerances Supplements Used

Lifestyle & Physical Activity Smoking Status Never Former Current Alcohol Use

Labs (if available)

Nutritional Concerns/Barriers Additional Notes