Moseleymcgill – Gastric Bypass

Gastric Bypass Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
Date of procedure:
Date Format: MM slash DD slash YYYY
Type of procedure (e.g. gastric bypass, banding, etc.):
Weight prior to procedure:
Current weight:
Has weight loss been stable/maintained?
- Yes
- No
Height:
Please provide details if any of the following complications have occurred:
Hemorrhage? If yes, provide details:
Obstruction? If yes, provide details:
Perforation? If yes, provide details:
Leaks? If yes, provide details:
Abnormal liver function studies? If yes, provide details:
Hypoglycemia? If yes, provide details:
Anemia? If yes, provide details:
Nutritional deficiencies? If yes, provide details:
Vomiting or nausea? If yes, provide details:
Change in bowel habits/diarrhea due to dietary modifications? If yes, provide details:
Failure to lose weight? If yes, provide details:
Problems retaining weight? If yes, provide details:
Dumping syndrome? If yes, provide details:
Any history, past or present, of associated chronic disease including diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, or cardiovascular disease?
- Yes
- No
If yes, provide details below:
Medications
Click the + sign to add additional medications.
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
List any other major health problems the client has:
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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Gastric Bypass

Gastric Bypass Questionnaire