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English (US)
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Medical Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Weight
*
What surgery are you interested in?
*
Gastric Bypass
Gastric Sleeve
Revision Surgery
Mini Gastric Bypass
Have you had any weight loss surgery before?
*
Yes
No
Please specify the weight loss surgery you've previously had:
*
Do you have sleep apnea?
*
Yes
No
Do you use a CPAP machine?
*
Yes
No
Do you have a pre-existent metabolic condition?
*
Yes
No
Please specify your pre-existent metabolic condition:
*
Do you have any of the following metabolic conditions?
Diabetes
Hypothyroidism
Hyperthyroidism
Arterial hypertension
Dyslipidemias (cholesterol and triglycerides
None
Other
Do you have a pre-existent cardiac condition?
*
Yes
No
Please specify your pre-existent cardiac condition:
*
Have you had any of the following cardiac conditions?
Heart attacks
Heart failure
Stenosis of cardiac valves (aortic and tricuspid)
None
Other
Do you have a pre-existent digestive condition?
*
Yes
No
Please specify your pre-existent digestive condition:
*
Do you take any medications? If so, please specify:
*
Do you smoke?
*
Yes
No
Please specify your smoking frequency:
*
Do you consume any drugs?
*
Yes
No
Which drugs and with what frequency?
*
Do you have any additional questions or comments?
Dr
Procedimiento
Especialidad
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