CONTACT US

Address

Address

Bariatric Institute of Kentucky
Samaritan Medical Plaza
125 E. Maxwell St, Suite 201
Lexington, Kentucky 40508

Telephone Numbers

Office: (859) 233-0572
Fax: (859) 233-0651

Email
bariatricinstituteky@yahoo.com

     Reply Form

*Name:

*Birth Date:  *Age:

*Address:

*City: * State:  *Zip: 

Telephone - *Days:  Evenings:

Email:

Insurance Carrier:

*Height: *Weight:

Are you over 100 pounds overweight?

Number of years severely overweight:

*How did you here about us?
Friend/Patient
TV
Radio
Newspaper
Billboard
Internet
Physician, if so who
Other



* required fields

Weight Loss Methods Tried:

Weight Watchers--How Long Did You Use? Year

Jenny Craig--How Long Did You Use? Year

Opti Fast--How Long Did You Use? Year

Nutri System--How Long Did You Use? Year

Redux--How Long Did You Use? Year

Phen/Fen--How Long Did You Use? Year

Diabetic Diet--How Long Did You Use? Year

Calorie counting--How Long Did You Use? Year

Physician supervised program--How Long Did You Use? Year

Dietitian supervised program--How Long Did You Use? Year

Any other diet pills not listed (If so, what?) --How Long Did You Use? Year

If you have been enrolled in a diet clinic please list:

Do You Have Any Of The Following Conditions?

Asthma--What medications do you take?

Hypertension--What medications do you take?

Diabetes--What type: Medication

Joint pain--Where?

Heart problems (If yes, what?)

Sleep apnea --CPAP --BIPAP

Severe gastro esophageal reflux

Pickwickian syndrome

Elevated lipid level or cholesterol level

Kidney problems

Thyroid--What medications do you take?

Cancer--What type? When?

Liver--What medications do you take?

Chronic phlebitis and/or chronic venous insufficiencies

Have You Ever Had Any Of These Surgeries Before?

Previous weight loss surgery (If yes, what type?)

Gallbladder removed--When?

Tonsils removed--When?

Uterus/ovaries removed--When?

Back surgery--When?

Joint surgery (If yes, what type?) When?

Appendix removed --When?

Heart surgery--When?

Lung surgery--When?

C-Section--When?

Any surgery not mentioned (If yes, what type?)

Important Questions

*Are you agreeable to accept a blood and/or blood product transfucsion? Yes No

*Are you wheelchair dependent? Yes No

*Do you use home oxygen therapy? Yes No * required fields

Additional Comments Or Questions

Click here for Faxable Letter Of Release For Other Documents Pertaining To Being Overweight