Initial Intake Form
Click here to download a printable version of the Initial Intake Form
Name:
Phone:
Date of Birth:
Address:
City, State, ZIP:
Height:
Weight:
Insurance:
Primary Care
Physician:
Have you ever been on a medically supervised diet?
Yes
No
If so, when?
How Long?
Pounds Lost?
Do you smoke?
Yes
No
If yes, how much and for how long?
Current Medical Conditions
Diabetes
High Cholesterol / Triglycerides
High Blood Pressure
Sleep Apnea
Heart Disease
Depression / Bipolar Disorder
Lung problems (asthma, shortness of breath, COPD)
Other:
Please list current medications, including dosage, reason for taking and the perscribing doctor:
How long have you been researching weight loss surgery?
Why do you want this surgery?
What are your expectations from surgery?
Do you have specific goals you would like to achieve? Please list:
What are your current exercise habits?
What type of exercise habits do you plan?
If desired, please list any other information you would like us to know:
"Life is good. For the first time in my life, I actually feel like I'm living life, instead of standing on the sidelines and watching it pass by. I'm happy."
Delene Evans, Elk Grove, CA
Dr. Koura
