To submit this Nutrition Questionnaire, email it to your healthcare provider at [provider's email]. Alternatively, fax the completed form to [fax number] or use the online submission form found on [provider's website]. If you prefer physical submission, print the form and deliver it to [address]. Make sure to include your contact information to avoid any delays in processing.

Important dates to keep in mind when submitting this form include regular clinic appointments in 2024 and 2025, with an emphasis on timely submission prior to these dates for optimal care. Make sure to consult with your healthcare provider for specific deadlines relevant to your surgery.

The purpose of this Nutrition Questionnaire is to collect vital information regarding your weight history, diet, exercise habits, and triggers that affect your eating patterns. This information is crucial for healthcare professionals to provide tailored advice and support for weight loss surgery candidates. Completing this form accurately will help create an effective weight management strategy that suits your individual needs.

• 1. Date: Enter the date of filling out the questionnaire.
• 2. Name: Provide your full name.
• 3. Current Weight: State your current weight.
• 4. Goal Weight: Indicate your desired weight goal post-surgery.
• 5. Weight Problem Onset: Describe when your weight issues began.
• 6. Reason for Weight Gain: Select reasons related to your weight gain.
• 7. Highest Adult Weight: Provide your highest recorded weight.
• 8. Average Weight Loss: List the average pounds lost in past weight loss attempts.
• 9. Successful Diet: Discuss your most successful diet and why it worked.
• 10. Exercise Frequency: Indicate if you exercise and detail your activities.
• 11. Meal Frequency: How many meals do you eat per day?
• 12. Snacking Habits: Describe your snacking frequency and type of snacks.
• 13. Beverage Consumption: List beverages consumed and daily amounts.
• 14. Alcohol Consumption: Specify if you drink alcohol and details about it.
• 15. Multivitamin Intake: Indicate if you take a multivitamin.
• 16. Smoking Habits: State your smoking status and history.

If you fail to submit this form, your healthcare team may not have essential information needed for your weight management plan. Without these details, it could delay your eligibility for weight loss surgery. Ensure you complete and submit this form accurately to facilitate the process.

• Inadequate Information: Missing information can lead to poor dietary guidance.
• Delay in Surgery Approvals: Incomplete forms can slow down the evaluation process for surgery.
• Failure to Address Needs: Without submission, your healthcare provider cannot address your unique weight loss needs.

• 1. Initial Clinic Visit: Complete this form before your first appointment regarding weight loss surgery.
• 2. Follow-Up Assessments: Use the form during follow-up visits to track progress.
• 3. Support Group Meetings: Bring this form to ensure your support group understands your dietary needs.