Medical History Form | Bariatric surgery

Full name*

First NameLast Name

What is your Gender*

MaleFemaleOther

Age*

Date of birth*

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?*

How long have you been overweight?*

What have you done to try to lose weight?*

Are you a snacker?*

YesNoSometimes

Are you a volume eater?*

YesNoSometimes

Do you eat a lot of sweets?*

YesNoSometimes

Do you frequently eat fast food and/or drink carbonated beverages?*

YesNoSometimes

What foods or drinks cause you digestive problems? *

How often do you consume alcohol?*

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?*

Check the conditions that apply to you:*

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*

YesNo

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 BypassGastric SleeveGastric Plication

Preferred surgery date*

Upload related medical documents

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I declare that I have truthfully completed this form and have not made any purposeful omissions.

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Bariatric Surgery Application Form

Please tell us about your diet history

Please tell us about your personal health history

Patient declaration