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PATIENT INFORMATION
Please fill out all fields.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Mes
-
Día
Año
Gender
*
Female
Male
Other
Address
*
Street address
Dirección de la calle Línea 2
City
State / Province
Zip Code
Phone Number
*
Favor ingrese un número de teléfono válido.
Email Address
*
example@example.com
Age
*
Must be over 18 years old*
Insert your Body Mass Index
*
Don't know your BMI? Calculate below
Calculate your Body Mass Index
Please indicate which surgery you are interested in:
*
Weight Loss Surgery
Plastic Surgery
Ozempic Compound (Semaglutide)
Mounjaro Compound (Tirzepatide)
How did you find out about us?
*
CURRENT MEDICATION (INCLUDE VITAMINS, OVER-THE COUNTER MEDICATION, ETC.)
Note: Pl. fill the below fields using commas separations as shown below:
Name of medication, Dosage, Frequency of use, Indications, Start date (Please list all your current medications)
*
Example: (A) Metformin, one pill every 8 hours.
LIST OF ANY MAJOR ILLNESSES
Note: Pl. fill the below fields using commas separations as shown:
Date, Illness, Treatment, Outcome
*
LIST PREVIOUS SURGERIES
Note: Pl. fill the below fields using commas separations as shown:
Surgery, Date, Reason
*
Have you ever had surgery to aid weight loss?
*
Yes
No
DIET HISTORY
How long have you been overweight?
*
Have you tried diet pills?
*
Yes
No
What have you done to try to lose weight?
*
What kind of exercise program have you tried?
*
REVIEW OF SYMPTOMS
Unless otherwise specified, mark the correct option and provide any information about your current status.
Please select any of the following symptoms or conditions that apply to you:
*
Frequent or severe fatigue.
Frequent or severe weakness.
Fever, chills or night sweats.
Frequent or severe headaches.
Any history of head injury with loss of consciousness.
Hearing problems.
Ear pain.
Nasal congestion.
Chronic sinus congestion.
Frequent bloody nose.
Dentures.
Sores in mouth.
Wheezing.
Coughing.
Breast lump, pain or discharge.
Heart murmur.
High blood pressure.
Chest pain with exercise or activity.
Any sexually transmitted disease that was not treated.
Birth control.
Infertility.
Anemia.
Any history of blood transfusion.
Bleeding tendency.
Convulsions, seizures.
Paralysis.
Numbness or tingling.
Memory loss.
Depression.
Anxiety.
Mood swings.
Sleep problems.
Drug or alcohol abuse.
Chronic skin rash or hives.
Asthma.
Allergic to latex.
Please list any additional information you believe would assist in your health planning:
*
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