Bariatric Surgery Application Form
Full name
*
First Name
Last Name
What is your Gender
*
Male
Female
Other
Age
*
Date of birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number (with country code)
*
Email Address
*
example@example.com
What is Your Weight?
*
What is Your Height?
*
What is Your BMI?
What was your highest weight ever?
*
Please tell us about your diet history
How long have you been overweight?
*
What have you done to try to lose weight?
*
Are you a snacker?
*
Yes
No
Sometimes
Are you a volume eater?
*
Yes
No
Sometimes
Do you eat a lot of sweets?
*
Yes
No
Sometimes
Do you frequently eat fast food and/or drink carbonated beverages?
*
Yes
No
Sometimes
What foods or drinks cause you digestive problems?
*
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Do you take or have you ever taken illegal drugs?
*
Do you smoke? If yes, please tell us how often and how much:
*
Do you have any other addictions?
*
Please tell us about your personal health history
Check the conditions that apply to you:
*
Diabetes
Cancer
Overweight
Obesity
Heart disease
High blood pressure
Gastric symptoms
None
Do you experience shortness of breath with physical activity?
*
Do you exercise regularly?
*
Do you have or had asthma?
*
Do you have thyroid problems?
*
Do you have any allergies?
*
Have you been diagnosed with fatty liver, cirrhosis, hepatitis or any other liver disease?
*
Do you have indigestion or heart burn?
*
Have you been diagnosed for lupus?
*
Have you been diagnosed HIV positive
*
Yes
No
Please tell us about your family health history. If your family member was diagnosed with any of below mentioned diseases tell us who from your family and what type:
*
Please list any previous surgeries you have had with surgery type, date and reason:
*
Please list any current medications you are taking:
*
Please list any major illnesses you have had:
*
Please list any additional information you believe would assist in your health care planning:
Preferred type of surgery
*
Gastric Bypass
Gastric Sleeve
Gastric Plication
Preferred surgery date
*
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Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Signature
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