TreVita Health Questionnaire

Health Questionnaire

Get qualified for a weight loss procedure & receive a quote
Submitted Date

MonthDayYear
Date
Desired Surgeon*
Tell us about yourself!
Patient's Legal Name*

First NameLast Name
FemaleMale
Date of Birth*

MonthDayYear
Select or type your date of birth
Age
Height (ft)*
Feet
Height (in)*
Inches
Weight (lbs)*
Pounds
BMI
Procedure of Interest*
When would you like to have surgery?*
InterestedNot Interested
Health History
YesNo
What surgery did you have?*
Year of previous surgery
LaparoscopicOpenUnsure
How much did you weigh BEFORE your 1st weight loss surgery?*
How much did you weigh 1 year AFTER your 1st weight loss surgery?*
Did you eat large quantities of food AFTER your 1st weight loss surgery?*
Where did you get your 1st weight loss surgery? (United States? Tijuana?)*
Are you having any discomfort or Acid Reflux now?*
How much weight would you like to lose after your next surgery?*
ChildhoodPubertyAdulthoodAfter PregnancyAfter Traumatic Event
AIDSAsthmaAnemiaAnxietyBone or Joint ProblemsCancerCirrhosisCrohn's DiseaseDiabetesFatty LiverHepatitisHIVLiver DiseaseLupusLung Disease (COPD)PCOSRheumatoid ArthritisSchizophreniaSleep ApneaThyroid ProblemsUlcerative ColitisNone of the aboveOther / More Details
Other diagnosis and/or additional details*
NoneAnti-anxietyAnti-depressantAnti-diabeticBlood PressureHormone TherapyNeurolepticPain medicationStatinSteroidOther / More Details
Other medications and/or additional details*
List all hormone therapies & how frequently you take each treatment*
YesNo
Year of last stroke?*
List all medications you are taking to prevent future strokes*
YesNo
Please list blood thinners (NSAID's, Advil, etc.)
Blood Type*
YesNo
YesNo
YesNo
NoneEggsFishMeatMilkPeanutsPoultrySesameShellfish (such as shrimp)SoyTree nuts (such as walnuts and cashews)WheatOther / More Details
Other food allergies, restrictions, and/or additional details*
NoneAntibiotics -- amoxicillin (Moxatag), ampicillin, penicillin (Bicillin L-A), tetracycline, and othersAntiseizure drugs -- carbamazepine (Tegretol), lamotrigine (Lamictal), phenytoin, and othersAspirinChemotherapy drugsHIV drugs -- abacavir (Ziagen), nevirapine (Viramune), and othersInsulinMonoclonal antibody therapy -- cetuximab (Erbitux), rituximab (Rituxian) and othersMuscle relaxers given by IV -- atracurium, succinylcholine, or vecuroniumNonsteroidal anti-inflammatory drugs like ibuprofen and naproxenSulfa drugsOther / More Details
Other medication allergies and/or additional details*
NoneBiotinCalcium CitrateCollagenCoQ10Ferrous sulfateFish oilIronMagnesiumMultivitaminOmega 3PotassiumPrebioticsProbioticsVitamin AVitamin BVitamin CVitamin DVitamin EVitamin KZincOther / More Details
Other supplements, vitamins, and/or additional details*
Shortness of breath with physical activityHigh Blood PressureChest PainNone of the above
YesNo
YesNo
YesNo
Cardiology
YesNo
Year of diagnosis
Describe your treatment
YesNo
Digestion
Abdominal PainAcid RefluxBloody StoolsChanges in Bowel MovementDiverticulitisHeartburnHemorrhoidsHiatal HerniaIndigestionUlcersNone of the above
Additional Information
Is there anything related to your medical history that has not been covered?
Do you have any access requirements you would like the team to be aware of? For example, wheelchair accessibility.
Do you have any questions for your surgeon or the medical team?
Patient Contact Information
Email*

Confirmation Emailre-enter your email address
Cell Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
PhoneEmail
Time Zone*
How did you hear about us?*
Other way you heard about us?*
Who can we thank for referring you?

First NameLast Name
Necessary Documentation
It is important to have proper documentation to cross the international border. If you do not have a passport and need more assistance please call us at 1-(866)-858-5593.
Consents
I understand that full disclosure is necessary to my medical safety. I acknowledge that I have provided all of my personal and medical history accurately.
I, the undersigned patient, parent, or legal guardian, do hereby authorize TreVita LLC, to release any and all medical information to all physicians and/or third parties that may potentially be involved in my care and treatment.
By submitting this form, I authorize TreVita LLC to contact me via telephone or SMS at the number I provided above about TreVita's products, events, and services using an automatic telephone dialing system and/or artificial or prerecorded voices. Msg and data rates apply. You may receive email updates from TreVita, LLC. Consent is not required to obtain services from TreVita. I may opt out of marketing messages at any time by replying "Stop" or unsubscribing. I agree to TreVita's Terms of Service and Privacy Policy.
Your signature*
Please verify that you are human*
Reply-to Email
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Health Questionnaire

Tell us about yourself!

Health History

Cardiology

Digestion

Additional Information

Patient Contact Information

Necessary Documentation

Consents