Meal Planning

Be Slim Bariatrics Meal Planning Intake Form

The meal plan program will be provided each month - up to five months post op. This form will help our nutritionist to cater your meal plan to your very own tastes and needs.

*Patients who received promotional pricing do not qualify for Post Operative Meal Planning. Please talk to your patient coordinator for meal planning pricing if you have received a promotional weight loss surgery package.

Meal Planning Program Includes

5 breakfast options
5 lunch options
5 dinner options
Snack options
Recommended daily amount of water
Adjustments in supplement recommendations (vitamins, protein shake, etc.)

*Does not include actual food items.

FULL NAME:*

First Name

Last Name

E-MAIL:*

AGE:*

GENDER:*

WEIGHT BEFORE SURGERY:*

ACTUAL WEIGHT:*

HEIGHT*

WAIST CIRCUMFERENCE:*

HIP CIRCUMFERENCE:*

SURGERY DATE:*

WHAT TYPE OF BARIATRIC SURGERY DID YOU HAVE?*

Select bariatric surgery type performed

DID YOU HAVE ANY OTHER SURGERY?

List any other surgeries performed that day

ANY DIAGNOSED DISEASE?

List any diseases here

Diet & Fitness

DO YOU HAVE CONSTIPATION?*

HOW MANY MEALS ARE YOU EATING PER DAY? AND QUANTITIES PLEASE.*

PLEASE WRITE HERE EVERYTHING YOU CONSUMED YESTERDAY. -BREAKFAST: -LUNCH: -DINNER: -SNACKS:*

ARE YOU ALLERGIC TO ANY FOODS?*

List food types

WHAT FOODS DO YOU DISLIKE?*

List food types

WHICH FOODS ARE YOUR FAVORITES?*

List food types

WHAT SUPPLEMENTS (VITAMINS) ARE YOU CURRENTLY CONSUMING? WHAT TYPE & BRAND.*

ARE YOU CURRENTLY TAKING ANY PROTEIN SHAKES? WHAT BRAND?*

HOW MANY OZ OF WATER DO YOU CONSUME PER DAY?*

WHAT OTHER TYPE OF LIQUID DO YOU CONSUME? LIST AMOUNTS.*

ARE YOU WALKING A FEW MILES? HOW MANY DAYS A WEEK AND HOW LONG?*

COMMENT