Bariatric Surgery Pre-Operative Checklist
Patient Name
Date of Birth
Surgery Date
Surgeon
Procedure Type
Gastric Bypass
Sleeve Gastrectomy
Adjustable Gastric Band
Other
Pre-Operative Checklist
Medical Evaluation Completed
Nutrition Assessment Completed
Psychological Evaluation Completed
Required Lab Tests Done
EKG Completed
Chest X-Ray Completed
Medical Clearance Obtained
Insurance Authorization Received
Pre-Op Class Attended
Anesthesia Consultation Completed
Additional Notes
Pre-Op Nurse Name
Date