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Confidential Health History Assessment
🔒 Privacy & Security Notice: Your privacy is our top priority. This form is fully encrypted and only Dr Sandy and our authorized medical staff will have access to the information provided.
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1
Full Name
*
This field is required.
First Name
Last Name
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2
Age
*
This field is required.
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3
Phone Number
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4
Email Address
*
This field is required.
example@example.com
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5
Select your US State
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6
Gender
*
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Male
Female
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7
Height & Weight Information
*
This field is required.
Please provide your current measurements to calculate your BMI. This helps Dr. Sandy determine the safest surgical approach for you.
Imperial (lbs, ft/in)
Metric (kg, cm)
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8
Weight (lbs)
*
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Lbs
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9
Weight (Kg)
*
This field is required.
Kg
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10
Height (Feet' Inches")
*
This field is required.
Please Select
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
Please Select
Please Select
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
Feet' Inches"
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11
Height (cm)
*
This field is required.
To convert from mts to cms, multiply by 100. Eg: 1.65m = 165cm
cm
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12
Your BMI:
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13
Your BMI is:
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14
Have you had any previous bariatric surgeries?
YES
NO
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15
Procedure of Interest
*
This field is required.
The procedure you are considering. If you're unsure select "Not Sure" and Dr. Sandy will recommend the best option based on your health history.
Please Select
Gastric Sleeve (VSG)
Gastric Bypass (RNY)
Mini-Gastric Bypass (MGB)
Duodenal Switch (DS)
Single Incision Gastric Sleeve (SILS)
Endoscopic Sleeve Gastroplasty (ESG)
I’m not sure / Need a recommendation
Please Select
Please Select
Gastric Sleeve (VSG)
Gastric Bypass (RNY)
Mini-Gastric Bypass (MGB)
Duodenal Switch (DS)
Single Incision Gastric Sleeve (SILS)
Endoscopic Sleeve Gastroplasty (ESG)
I’m not sure / Need a recommendation
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16
Specify your desired conversion
*
This field is required.
Eg. Converting a previous Gastric Sleeve to SADI-S (Select SADIS)
Conversion to Gastric Sleeve
Conversion to Gastric Bypass
Conversion to Duodenal Switch (SADI-S)
I’m not sure / Need a recommendation
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17
How many previous weight loss surgeries have you had?
*
This field is required.
(Excluding the one you are inquiring about now)
Please Select
1
2
3 or more
Please Select
Please Select
1
2
3 or more
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18
Which was your most recent bariatric procedure?
*
This field is required.
Select the last surgical bariatric procedure you had
Please Select
Gastric Sleeve (VSG)
Gastric Bypass (RNY)
Mini-Gastric Bypass (MGB)
Duodenal Switch (DS)
Gastric Lap band (LAP-Band)
Revision Surgery (Adjusting a prior bariatric surgery)
Please Select
Please Select
Gastric Sleeve (VSG)
Gastric Bypass (RNY)
Mini-Gastric Bypass (MGB)
Duodenal Switch (DS)
Gastric Lap band (LAP-Band)
Revision Surgery (Adjusting a prior bariatric surgery)
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19
Date of most recent procedure
*
This field is required.
-
Date
Month
Day
Year
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20
Reason for seeking a revision
Please select all that apply
Weight regain
Reflux / GERD
Malnutrition / Vitamin deficiency
Excessive weight loss
Insufficient weight loss
Complications / Persistent pain
Other
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21
Please Specify
Reason for seeking a revision
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22
Have you had any 'open' surgeries (large incision)?
*
This field is required.
This does not include laparoscopic or 'keyhole' procedures.
YES, Open Incision
NO
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23
Have been diagnosed with?
*
This field is required.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Asthma / Respiratory Issues
High Blood Pressure (Hypertension)
High Cholesterol
Sleep Apnea
Asthma or COPD
Heart Disease / Arrhythmia
Type 1 or 2 Diabetes
Pre-diabetes / Insulin Resistance
Thyroid Disorder (Hypo/Hyperthyroidism)
GERD / Acid Reflux
Fatty Liver Disease
Asthma / Respiratory Issues
High Blood Pressure (Hypertension)
High Cholesterol
Sleep Apnea
Asthma or COPD
Heart Disease / Arrhythmia
Type 1 or 2 Diabetes
Pre-diabetes / Insulin Resistance
Thyroid Disorder (Hypo/Hyperthyroidism)
GERD / Acid Reflux
Fatty Liver Disease
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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24
Heart Disease?
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25
Heart Disease / Arrhythmia Details
*
This field is required.
Please specify your diagnosis, any previous cardiac procedures (stents, pacemakers, etc.), and your current medications or treatments.
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26
Have you ever tested positive for HIV or Hepatitis?
YES
NO
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27
Lifestyle & Current Care
*
This field is required.
Briefly list your allergies, current medications, and habits. These details ensure a smooth recovery and personalized care.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Do you currently smoke? (Vaping/Tobacco)
Do you drink alcohol? (Regularly +2/wk)
History of blood clots? (DVT/Pulmonary Embolism)
Do you take blood thinners?
Do you use any Recreational Substance (eg. marijuana, others)
Do you currently smoke? (Vaping/Tobacco)
Do you drink alcohol? (Regularly +2/wk)
History of blood clots? (DVT/Pulmonary Embolism)
Do you take blood thinners?
Do you use any Recreational Substance (eg. marijuana, others)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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28
Use Drugs?
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29
Recreational Substance Use
To ensure your safety during anesthesia, please disclose any use of recreational substances (including marijuana, tobacco, or others).
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30
List any known drug allergies
(Ej: Penicillin, Latex, etc.)
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31
Current medications & dosages
Any medication you are taking or in regular prescription
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32
Have you had any prior abdominal surgeries (excluding weight loss)?
(e.g., gallbladder, appendix, C-section, hernia, etc.)
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33
Were any of these procedures performed as 'open' surgery?
*
This field is required.
(Large, traditional incision vs. small laparoscopic incisions)
YES, Open Incision
NO, Laparoscopic (Keyhole)
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34
Any known surgical conditions you would like Dr. Sandy to address?
(e.g., Hiatal Hernia Repair, Gallbladder removal, etc.)
YES
NO
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35
Additional Surgical Procedures
Specify known surgical conditions you would like Dr. Sandy to address within your surgical plan?
Please Select
Hiatal Hernia Repair
Gallbladder Removal (Cholecystectomy)
Umbilical Hernia Repair
Adhesiolysis (Scar Tissue Removal)
Incisional Hernia Repair
Please Select
Please Select
Hiatal Hernia Repair
Gallbladder Removal (Cholecystectomy)
Umbilical Hernia Repair
Adhesiolysis (Scar Tissue Removal)
Incisional Hernia Repair
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36
Base_Cx
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37
Base_BMI
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38
Base_Rev
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39
Extra_1
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40
Extra_2
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41
Extra_3
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42
Extra_4
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43
Extra_5
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44
VACIO
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45
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