Bariatric Questionnaire

Do I qualify for weight loss surgery?

Start Your Weight Loss Journey Today

1. Have you thoroughly explored other treatments for obesity?

Yes. I have tried one or more diet and exercise programsI've thought about it, but have never really gotten serious about itNo

2. How much weight do you want to lose?

0-30 pounds30-60 pounds60-100100 +

3. What's Your Body Mass Index
(Calculate your BMI)

25-29.930-34.935-39.940-49.950-59.960 +

4. Do you have any weight-related health issues
(diabetes, hypertension, sleep apnea, joint problems, etc)?

Type 2 DiabetesHigh Cholesterol DepressionHigh Blood pressure (Hypertension)Sleep ApneaHeart DiseaseJoint and Bone PainGERD/RefluxReproductive Health

5. Do you currently have insurance? If so, what insurance company?

First Name

Last Name

Phone Number

Name of Insurance

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(718) 257-0211

At Brooklyn Queens Surgical, we provide the highest quality eye care to all our patients. Schedule your appointment today.

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