Weight Loss Surgery Questionaire
Mountain View Center
Is Weight Loss Surgery for Me?
If you have remained severely overweight after other serious and sustained attempts to lose weight, and especially if you have obesity-related medical conditions, surgery may be the appropriate next step. For some, intensified behavioral and medical efforts to control weight may be more appropriate. Please answer the following questions to help determine if you are a possible candidate for surgery.
1. Are you unlikely to lose weight successfully by methods other than bariatric surgery?
__ Yes __ No
2. Are you well informed about the surgical procedure, risks and the effects of treatment?
__ Yes __ No
3. Are you committed to losing weight and improving your health?
__ Yes __ No
4. Are you willing to make the following changes in your lifestyle for the rest of your life:
Are you willing to chew your food completely?
__ Yes __ No
Are you willing to not eat large meals?
__ Yes __ No
Can you accept not being able to eat foods that your body does not tolerate?
__ Yes __ No
Are you willing to exercise daily?
__ Yes __ No
Are you willing to take vitamin and mineral
supplements for life?
__ Yes __ No
Are you willing to eat three meals per day, give priority to protein intake, and to sip water frequently?
__ Yes __ No
Are you willing to give up gum, popcorn, alcohol, carbonated and caffeinated beverages?
__ Yes __ No
5. Are you aware that there are occasional failures, potentially serious complications and infrequent deaths after bariatric surgery?
__ Yes __ No
6. Will you commit yourself to lifelong medical follow up?
__ Yes __ No
7. Do you have a body mass index (BMI) of 40 or more? (See below to determine your BMI.)
__ Yes __ No
8. Do you have an obesity-related health problem such as sleep apnea, diabetes or heart disease? (If your BMI is 35 or more and you have one of these severe conditions, you may qualify for the surgery.)
__ Yes __ No
If you answered "yes" to the above questions, you may be a good candidate to undergo surgery for weight loss.
To determine your BMI, use this link to access our Health Education BMI Calculator
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