Bariatric Surgery Psychosocial Evaluation Report

Patient Name: [Patient full name]
DOB: [MM/DD/YYYY]    Age: [Age in years]    MRN: [Medical record number / N/A]
Date of Evaluation: [MM/DD/YYYY]    Date of Report: [MM/DD/YYYY]
Evaluator: [Evaluator name, degree, credentials]
Referral Source: [Referring provider/clinic]
Procedure Under Consideration: [Specific procedure / TBD per surgical team]

[Statement confirming the patient was informed that the results of this evaluation will be shared with the multidisciplinary bariatric surgery team, and consent to share was obtained.]

Executive Summary

• Strengths and protective factors: [Brief summary of personal, social, and treatment-related strengths supporting surgical success]
• Key concerns by domain:
  • Eating behavior: [Key issues / None significant]
  • Mood/anxiety: [Key issues / None significant]
  • Substance use: [Key issues / None significant]
  • Social supports: [Quality/availability of supports]
  • Adherence risk: [Drivers of adherence risk]
• Safety summary (suicidality/self-harm): [No current risk / Historical only / Current passive SI without intent / Current active SI with plan/intent] (State explicitly even if negative.)
• Adherence risk rating: [Low / Moderate / High] — [One-sentence rationale]
• Readiness/Clearance Impression: [Cleared to proceed / Cleared with recommendations / Recommend postponement pending specific conditions / Not recommended at this time]
• Required next steps: [Concise list of must-do items for surgical progression / None]
• Recommended optimization steps: [Concise list of suggested items to improve outcomes]

Weight and Eating History

Current weight/BMI: [Value and units] ([chart-derived / patient-reported])

Patient's understanding of weight gain drivers: [Brief synthesis of patient's perspective on biological, behavioral, environmental, and psychosocial contributors]

Current eating pattern and meal structure: [Typical day, meal timing, protein/produce emphasis, beverage intake, mindful eating practices]

• Loss-of-control eating: [Denied / Endorsed / Not assessed (reason)] (If endorsed: [frequency], [context/triggers], [associated distress].)
• Binge eating episodes: [Denied / Endorsed / Not assessed (reason)] (If endorsed: [frequency], [objective amount vs. subjective binge], [loss of control details].)
• Grazing/snacking: [Denied / Endorsed / Not assessed (reason)] (If endorsed: [frequency/pattern], [triggers].)
• Night eating: [Denied / Endorsed / Not assessed (reason)] (If endorsed: [timing], [caloric load], [sleep association].)
• Emotional eating: [Denied / Endorsed / Not assessed (reason)] (If endorsed: [triggers], [coping alternatives used].)
• Compensatory behaviors (purging, laxatives, diuretics, fasting, excessive exercise): [Denied / Endorsed / Not assessed (reason)] (If endorsed: [types], [frequency], [timeline].)

Weight history (onset/trajectory): [Onset of weight changes, life events, pregnancies, medications, medical conditions; highest adult weight: [value]; lowest adult weight: [value]; recent 6–12 month trend]

Prior weight management attempts: [Structured programs, medications, behavioral interventions, self-directed efforts — what helped, what didn't, duration/adherence as described]

Prior bariatric procedures: [Procedure type, date, initial outcome, complications, reasons for plateau/regain, follow-up adherence / None]

Psychiatric History and Current Symptoms

Current symptoms: [Mood, anxiety/panic, trauma-related symptoms, irritability, sleep disturbance, cognitive concerns — functional impact on work, relationships, self-care]

Past psychiatric diagnoses: [Diagnoses as reported/recorded / Denied]

Treatment history: [Therapy types, duration, response; psychiatric medications current/past with doses if known, adherence, side effects, prescriber follow-up; hospitalizations/ED visits/higher levels of care with dates if known]

Trauma history: [Brief, need-to-know summary relevant to perioperative coping/adherence / Not disclosed / Not clinically relevant] (Avoid unnecessary detail.)

Mental Status Examination:

• Appearance/behavior: [Description]
• Speech: [Rate/volume/fluency]
• Mood/Affect: [Patient-stated mood]; [Affect range/reactivity/appropriateness]
• Thought process/content: [Coherence/organization]; [Delusions/hallucinations: none / specify]
• Cognition: [Orientation], [Attention/concentration], [Memory]
• Insight/Judgment: [Brief appraisal relevant to surgery and health behaviors]
• Engagement/Reliability: [Effort/cooperation], [Estimated reliability of self-report]

Substance Use

(State current use status explicitly for each category. If active substance use disorder is suspected, document observed criteria, recommendations, and whether surgery should be deferred per program policy.)

• Alcohol: [Current use status: none / occasional / regular]; [Quantity/frequency]; [Heavy episodic use: denied / endorsed]; [AUD symptoms: denied / endorsed]; [Past treatment or recovery supports]; [Postoperative alcohol risk counseling: completed / pending]
• Nicotine: [Current use status: none / current / past]; [Amount/day]; [Quit attempts]; [Readiness to abstain if required]; [Biochemical verification if applicable]
• Cannabis: [Current use status: none / current / past]; [Route, frequency, purpose]; [Dependence features]; [Impact on appetite/eating]
• Other substances (opioids, stimulants, sedatives, illicit drugs): [Current use status]; [Prescribed vs. non-prescribed]; [Misuse indicators]; [Treatment history]; [Recovery supports]

Social History and Supports

Household and relationships: [Composition, stability, key relationships]

Primary postoperative supports: [Names/roles, availability for transportation, meal planning, monitoring, accountability] (Note quality of support, e.g., "supportive but works nights.")

Employment and finances: [Work schedule demands, leave availability, financial considerations impacting follow-up, food costs, vitamins]

Housing and access: [Stability/safety, access to kitchen/food storage, access to care/transportation]

Cultural/community factors: [Dietary practices, family expectations, community supports] (Include only if relevant.)

Understanding, Expectations, and Readiness

Goals for surgery: [Health-focused, functional, weight-related goals] (Include brief direct quotes if they clarify motivation or expectations.)

Expectations: [Anticipated weight loss trajectory, body changes, psychosocial changes and limitations]

Understanding of lifelong requirements: [Nutrition rules, vitamin regimen, follow-up schedule, physical activity, substance risk]

Behavior changes already initiated: [Meal structure, portion control, beverage changes, tracking, activity, support group/education attendance]; Confidence level: [0–10 rating]; Barriers: [Identified obstacles and proposed solutions]

Coping strategies for stress without overeating: [Skills/activities, social supports, treatment resources]

Safety Assessment

• Suicidal ideation: [Current: absent / passive / active]; [Plan/intent: none / present]; [Access to means: no / yes]; [Historical SI: denied / endorsed (timeline)]
• Suicide attempts/self-harm: [Denied / Endorsed (dates, methods, medical severity, context)]
• Protective factors: [Personal values, responsibilities, supports, treatment engagement]
• Current overall risk level: [Low / Moderate / High] — [Rationale]
• Immediate actions taken: [Safety planning, contacts, referrals, emergency steps / N/A - low risk]

(This section must contain explicit findings even when risk is absent.)

Psychological Testing

(Include only if standardized instruments were administered; omit section entirely if no testing performed.)

• Instruments: [Instrument names and versions], [administration mode]
• Scores and interpretation: [Score summaries with plain-language interpretation relevant to bariatric outcomes: adherence, coping, eating behavior, substance risk]
• Validity/limitations: [Response style, missing data, contextual factors]

Assessment and Formulation

[1–2 integrative paragraphs synthesizing how psychosocial factors interact with surgical readiness, including implications for adherence to diet/vitamins/follow-up, coping with postoperative stressors, likelihood of substitution behaviors, and persistence of problematic eating. Distinguish modifiable risks from potential contraindications.]

• Strengths: [Concise list]
• Risk Factors: [Concise list]

Diagnoses (DSM/ICD): [Diagnosis 1 (code)]; [Diagnosis 2 (code)]; [Rule out: specify only if necessary, with note on what additional data are needed]

Clearance Impression

Impression: [Cleared to proceed / Cleared with recommendations/conditions / Recommend postponement pending specified conditions / Not recommended at this time]

• Key factors driving this impression: [Bullet list of specific findings]
• If deferred/not recommended: [Required remediation steps and target interval or milestones for re-evaluation]

(When appropriate: "No psychosocial contraindications identified at this time.")

Recommendations

1. Required for surgical progression:
   • [Specific, operational steps (e.g., "Complete X sessions of nutrition counseling," "Document nicotine abstinence per program policy") / None]
2. Strongly recommended to optimize outcomes:
   • [Eating behavior targets]
   • [Mood/anxiety/trauma treatment optimization]
   • [Substance use counseling or monitoring plan]
   • [Support group participation]
   • [Practical adherence supports: reminders, written plans, teach-back education]
   • [Postoperative behavioral health follow-up plan with frequency and escalation triggers]
3. Optional supportive resources:
   • [Community programs, apps, educational materials, caregiver resources]

Patient feedback: [Results and recommendations were reviewed with the patient. Include their response, understanding, and stated next steps. Use brief direct quotes only if they clarify motivation or ambivalence.]

__________________________________
[Evaluator name, degree, credentials]
[License number and state]
[Contact information]