Post Live Info Session Registration

Thank you for attending a live information session with the Weight Loss Institute.

To complete your registration, please fill out the information below.

Please feel free to contact the Weight Loss Institute at 812-376-5640 with any questions.

Weight loss History

Please spend time completing this questionnaire in as complete detail as possible. This information is extremely important in determining your appropriateness for weight loss surgery.

Explanations

Please list any treatments for weight loss or eating in which you have participated for more than 1 month.

  1. Diets (Calorie counting, Weight Watchers, Jenny Craig, Atkins, Diabetic, Paleo, etc.)
  2. Diet Pills/Supplements (Over-the-counter supplements such as Ali, Fat Burners, Dexatrim etc.)
  3. Prescription Medications (Phentermine, Wellbutrin, Topomax, Orlistat, etc.)
  4. Medically Supervised Programs (Liquid protein diets, Psychotherapy, Dietitian Counseling)
  5. Other (Weight Loss Surgery, Exercise Programs, Overaters Anonymous, etc.)
  6. Please try to give as much specific information as possible.
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Eating Behavior History

Have you ever had an episode of binge eating:
Eating, in a 2-hour period, an amount of food that is definitely larger than most people eat in a smaller period?
A lack of control over eating during a meal/snack (i.e. a feeling that you cannot stop eating or control what or how much you eat)?
Please indicate on the scale below how characteristic the following symptoms are of your eating:
Feeling that I can't stop eating or control how much I eat
Eating more rapidly than usual
Eating until I feel uncomfortably full
Eating large amounts of food when not feeling physically hungry
Eating alone because I am embarrassed by how much I am eating
Feeling disgusted with myself, depressed, or very guilty after overeating
Have you ever self-induced vomiting after eating in control to "get rid" of food?
Have you ever used laxatives or diuretics to control your weight or "get rid" of food?
Do you avoid certain foods?
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Please answer the follow questions

Have you ever smoked cigarettes or cigars?
Do you currently?
Have you ever vaped or used E-cigs?
Do you currently?
Have you ever chewed tobacco?
Do you currently?
Have you ever drank energy drinks?
Do you currently?
Have you ever used caffeine tablets?
Do you currently?
Have you ever drank coffee?
Do you currently?
Have you ever drank tea?
Do you currently?
Have you ever drank sodas?
Do you currently?
Have you ever drank alcohol?
Do you currently?
Have you ever exercised for health or weight loss?
Do you currently?
Do you wear dentures?
Do you have difficulty chewing or swallowing?
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Certification

I certify that all the information I provide is true and complete to the best of my knowledge. I understand that it is important the physician has complete and accurate information in order to provide safe medical evaluation and care. I understand that this medical history is used in providing care through the Weight Loss Institute, and that some information may need to be shared with referring physicians/counselors.
As part of The Weight Loss Institute Program, we will periodically obtain pictures.
Can we release any records to family members?
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