Bariatric Psychological Evaluation

[YOUR COMPANY NAME]

Date: March 20, 2050

Overview:

This evaluation aims to assess various psychological factors that may impact your readiness for weight loss surgery. It is designed to understand your motivation, commitment, and potential barriers to lifestyle changes necessary for a successful surgical outcome. Your responses will guide the healthcare team in determining the most appropriate course of action for your care.

Purpose:

The purpose of this evaluation is to:

1. Assess your readiness and motivation for weight loss surgery.

2. Identify any psychological factors that may impact your ability to adhere to post-operative lifestyle changes.

3. Determine the level of support and resources you may need throughout the surgical process.

4. Ensure that you have realistic expectations about the outcomes of weight loss surgery.

5. Identify any potential barriers to successful weight loss and maintenance.

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Patient Information:

Name:

Date of Birth:

Date of Evaluation:

Evaluator's Name:

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Instruction:

Please carefully assess each criterion listed below and mark the appropriate response that best reflects your current thoughts, feelings, and behaviors related to weight loss surgery. Be honest and provide accurate information to help ensure the most effective evaluation of your readiness for this procedure.

• Not at all: This indicates that the statement does not apply to you or that you strongly disagree with it.

• Occasionally: This indicates that the statement applies to you sometimes or to some extent.

• Often: This indicates that the statement applies to you frequently or most of the time.

• Always: This indicates that the statement applies to you consistently or that you strongly agree with it.

Your responses will remain confidential and will only be used by the healthcare team to assess your readiness and suitability for weight loss surgery. If you have any questions or concerns about the evaluation criteria, please feel free to discuss them with your evaluator. Thank you for your cooperation.

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Evaluation Criteria

Criteria	Not at all	Occasionally	Often	Always
Motivation for weight loss surgery
Commitment to lifestyle changes
Understanding of risks and benefits of surgery
The support system in place for post-operative care
Awareness of emotional eating triggers
Previous attempts at weight loss and outcomes
Willingness to participate in pre-operative counseling
Realistic expectations about post-operative outcomes
Ability to comply with dietary and exercise regimen
Psychological history (e.g., depression, anxiety)
Current stressors and coping mechanisms
Understanding of the role of psychological support

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Comments/Feedback:

Please provide any additional comments or feedback regarding the patient's readiness for weight loss surgery:

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