Bariatric Surgery Nutrition Screening Form
Patient Name
Date of Birth
Date
Height (cm)
Weight (kg)
BMI
Medical History
List relevant medical conditions
Diabetes
Yes
No
Hypertension
Yes
No
Sleep Apnea
Yes
No
Other
Weight History
Previous weight loss attempts
Recent weight changes
Nutrition Assessment
Describe typical daily food and beverage intake
Vitamins/minerals/supplements
Behavioral Assessment
Eating behaviors/concerns
Smoking
Yes
No
Alcohol Intake
Physical Activity
Allergies/Food Intolerances
List allergies or intolerances