Bariatric Surgery Pre-Operative Assessment Form
Patient Information
Full Name
Date of Birth
Gender
Male
Female
Other
Height (cm)
Weight (kg)
BMI
Medical History
Comorbidities (Diabetes, Hypertension, OSA, etc.)
Previous Surgeries
Family History
Current Medications
Allergies
Lifestyle Assessment
Smoking Status
Never
Former
Current
Alcohol Use
None
Occasional
Regular
Physical Activity Level
Low
Moderate
High
Psychological Evaluation
Psychiatric History
Support System
Laboratory & Investigations
Relevant Labs/Results
Imaging/Other Investigations
Multidisciplinary Consultations
Dietitian
Psychologist/Psychiatrist
Other Specialties
Surgical Risk Assessment
ASA Grade
I
II
III
IV
Other Risks
Plan & Comments