Enter your ZIP code:

Please enter a 5 digit zipcode
No results...

Entering your zip code helps us to provide information and results that are more relevant to you.

Your privacy is important to us. By continuing, you agree to our Privacy Policy.

Get Care Now Pay My Bill News Careers Giving Patient Portal
Schedule an Appointment
Home Medical Services Bariatric Surgery Services Online Weight And Health Questionnaire

Weight and Health Questionnaire

Complete our secure online weight and health questionnaire below. Your answers will assist our team in creating a personalized plan tailored to your specific needs.

Medical emergencies

Call 911 if you are experiencing an emergency. Do not use this form.

Bariatric Assessment

Please provide your typical day/food intake:

Please provide any additional information that you think is important to understanding you, your weight control challenges and your goals.

Thank you

Thank you for submitting your online health and weight questionnaire. Someone from our team will call or email you within 3-5 business days to discuss your answers and options that best fit your needs. 

In the meantime, if you have any questions, feel free to call us at 888-454-8131.