Step 1 of 14

I am...

I am...*

Male

Female

Where are you in your weight loss surgery decision process?

Where are you in your weight loss surgery decision process?*

Step 1: Researching

Step 2: Evaluation Treatments

Step 3: Choosing My Doctor

Step 4: Ready to Book a Consult

What is your primary concern or question about bariatric surgery?

What is your primary concern or question about bariatric surgery?*

Can I afford it?

Is surgery right for me?

Will I keep the weight off long term?

What excites you about the prospect of weight loss surgery?

Tell us your primary motivators for seeking the procedure. Select all that apply.

What excites you about the prospect of weight loss surgery?*

Manage or Improve Obesity-Related Health Issues

Improve My Body Image

Improve My Quality of Life

Avoid Future Risks or Health Issues

Help with Fertility / Future Family Planning

Other

What is your height and weight?

Height (ft’ in”)*

Weight (lbs.)*

What is your date of birth?

Date*

Hidden

How old are you?

Hidden

How old are you?*

18-20

21-25

26-34

35-44

45-54

55-64

65-74

75+

Have you tried dieting in the past?

Have you tried dieting in the past?*

Yes

What diets have you tried or are currently following?

Select all that apply.

What diets have you tried or are currently following?*

Balanced Portions

Low Carb Diet (e.g., Atkins, Ketogenic)

Low Calorie Diet (e.g., Weight Watchers)

Low Fat Diet

Paleo

Mediterranean

Whole30

Vegan

Vegetarian / Plant-Based

Intermittent Fasting

South Beach

Raw Food Diet

Zone Diet

Other

Do you have any dietary restrictions?

Select all that apply.

Do you have any dietary restrictions?*

Gluten Intolerance / Celiac's Disease

Lactose Intolerant

Vegan

Vegetarian

Pescatarian

Specific Food Allergies

None

Do you have any physical limitations (other than your weight) that might prevent you from exercising?

Do you have any physical limitations (other than your weight) that might prevent you from exercising?*

Yes

What is your current level of exercise?

What is your current level of exercise?*

Sedentary

Light Activity

Moderate

Vigorous Activity

Maximal Activity

It Varies

Let us know if you have any of the following medical issues, as this will further inform our recommendations for you.

Let us know if you have any of the following medical issues, as this will further inform our recommendations for you.*

Diabetes

Sleep Apnea

High Blood Pressure (Hypertension)

Heartburn

Acid Reflux

Joint/Bone Issues

Depression

Cardiovascular Disease

Pulmonary Disease

Active Substance Abuse (Alcohol or Drugs)

Family History of Cancer or Heart Disease

Other

None

Which payment option describes you best?

Which payment option describes you best?*

Self-Pay

Financing

Private Insurance

I am Not Sure

All done! Enter your information below to receive your Personalized Results.

You will also receive an Email Course about your weight loss options from the team at B+A Medical. We keep your information safe and private. This is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. By providing your contact information, you agree to receive calls and texts to your phone number from B+A Medical.

First Name*

Last Name*

Email*

Phone*

Phone

This field is for validation purposes and should be left unchanged.

virtual bariatrics Tool