Am I a good candidate - Sydney Bariatric Clinic

This questionnaire is designed to help you understand if bariatric surgery might be a suitable option for you. Your answers will help us assess your potential candidacy. Please answer honestly.

Personal Information

Full Name:(Required)

Email:(Required)

Phone Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Medical History & Weight Information

1. What is your current height?(Required)

Centimeters(Required)

Feet(Required)

Inch(Required)

2. What is your current weight?(Required)

LBS(Required)

Kilogram(Required)

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Height M from CM

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Height M from FT+IN

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Final Height M

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Weight in kg from lbs

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Weight in kg

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Final weight in kg

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BMI

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BMI Score 10

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BMI Score 5

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BMI Score 0

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BMI Final Score

3. Have you ever been diagnosed with any of the following weight-related health conditions? (Select all that apply)(Required)

Type 2 Diabetes

High Blood Pressure (Hypertension)

High Cholesterol (Dyslipidemia)

Sleep Apnea

Joint Pain (e.g., knee, hip, back)

Gastroesophageal Reflux Disease (GERD)

Fatty Liver Disease (Non-alcoholic steatohepatitis - NASH)

Polycystic Ovary Syndrome (PCOS)

Depression or Anxiety related to weight

None of the above

4. Have you previously attempted to lose weight through diet and exercise?(Required)

Yes, multiple times

Yes, a few times

No, not extensively

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Score - Diabetes

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Score - High BP

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Score - High Chol

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Score - Sleep Apnea

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Score - Joint Pain

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Score - GERD

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Score - PCOS

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Score - Liver Disease

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Score - Depression

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Final Score - Comorbidities

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Score - Weight Attempt: Multiple

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Score - Weight Attempt: Few

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Final Score - Weight Attempts

5. Are you currently taking any medications for weight-related conditions?(Required)

Yes (Please list below)

Please list the medications you are currently taking(Required)

6. Have you had any other major surgeries in the past?(Required)

Yes (Please list below)

Please list other major injuries(Required)

Lifestyle & Motivation

7. How committed are you to making significant lifestyle changes (diet, exercise, follow-up appointments) after surgery?(Required)

Extremely Committed

Very Committed

Somewhat Committed

Not sure/Hesitant

8. Are you willing to attend regular follow-up appointments with your surgeon, dietitian, and other healthcare professionals for several years after surgery?(Required)

Yes, absolutely

Yes, I understand the importance

Maybe, I'll try my best

No, I prefer minimal follow-up

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Score - Extremely Committed

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Score - Very Committed

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Score - Somewhat Committed

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Final Score - Commitment

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Score - Followup - Absolutely

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Score - Followup - I understand

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Score - Followup - Maybe

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Score - Followup - Prefer Minimal

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Final Score - Followup

9. Do you have a support system (family, friends) who will encourage you throughout this journey?(Required)

Yes, a strong support system

Yes, some support

Not really

No, I'm on my own

10. Do you understand that bariatric surgery is a tool, not a cure, and requires lifelong commitment to achieve and maintain weight loss?(Required)

Yes, I fully understand

I have a general understanding

No, I thought it was a quick fix

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Score - Strong Support

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Score - Some Support

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Final Score - Support

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Score - Fully Understand

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Score - General Understanding

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Score - Understand - No

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Final Score - Understand

Medical Readiness

11. Have you been diagnosed with any of the following psychological conditions? (Select all that apply)(Required)

Uncontrolled Depression

Uncontrolled Anxiety Disorder

Bipolar Disorder

Schizophrenia

Eating Disorder (e.g., bulimia, binge eating disorder)

Substance Abuse (alcohol or drugs)

None of the above (or conditions are well-managed)

12. Are you able to participate in regular physical activity (e.g., walking for 30 minutes)?(Required)

Yes, easily

Yes, with some effort

No, due to physical limitations

No, due to lack of motivation

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Score - Pyschological - Uncontrolled Depression

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Score - Pyschological - Uncontrolled Anxiety

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Score - Pyschological - Bipolar

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Score - Pyschological - Schizophrenia

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Score - Pyschological - Eating Disorder

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Score - Pyschological - Substance Abuse

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Score - Pyschological - None of the above

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Final Score - Pyschological

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Score - activity - easily

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Score - activity - some effort

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Final Score - Activity

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Total Score

Disclaimer

This questionnaire is for informational purposes only and does not constitute a medical diagnosis or recommendation.
The results of this questionnaire will help us determine if you meet general criteria for bariatric surgery and if a formal consultation is recommended.
A comprehensive medical evaluation by our surgical team is required to confirm your candidacy.

Disclaimer(Required)

I have read and understood the disclaimer.

Personal Information

Medical History & Weight Information

Lifestyle & Motivation

Medical Readiness

Disclaimer

Ask a Question or Book Your Consultation

Send us a message and we’ll respond as soon as possible.

About Us

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	Shams A
	A wonderful team of specialists, dieticians, nurses and admin staff. Thank you to the wonderful team at Sydney Bariatric Clinic for your care. Have been and will continue to highly recommend them! Dr Ryan, Dr Tony and Cathy have been amazing to work with during my weight loss journey and not to mention the lovely receptionists!

	Cherin Johns
	Dr Ryan is the BEST. The whole team are wonderful. Dr Tony is also really good. I have lost 42kgs in 7 month with the assistance of the team including a dietician. My only regret is not going to see him earlier. Thank you so much for giving me my life back!

Sydney Bariatric Surgery:Am I a Candidate for Bariatric Surgery?

Personal Information

Medical History & Weight Information

Lifestyle & Motivation

Medical Readiness

Disclaimer

Ask a Question or Book Your Consultation

Send us a message and we’ll respond as soon as possible.

About Us

Our Clinics

Our Treatments

Stay Connected & Get Exclusive Invites

Sydney Bariatric Surgery:
Am I a Candidate for Bariatric Surgery?