PATIENT INFORMATION
Please indicate which surgery you are interested in:
Name
*
Last Name
*
Date of Birth
*
Gender
Address
Street address
Street line 2
City
State / Province
Zip code
E-mail Address
*
example@example.com
Cell Phone
*
Age
Insert your Body Mass Index
*
Possible date of Surgery
*
Please indicate which surgery you are interested in:
*
Please Select
Weight Loss Surgery
Plastic Surgery
Please, select one
*
Please Select
Gastric Sleeve
Gastric Bypass
How did you find out about us?
CURRENT MEDICATION (INCLUDE VITAMINS, OVER-THE COUNTER MEDICATION, ETC)
Note: Pl. fill the below fields using commas seperations as shown below:
Name of medication, Dose, How often taken, Purpose, When use started.
Example: (A) Metformin, one pill every 8 hours.
LIST OF ANY MAJOR ILLNESSES
Note: Pl. fill the below fields using commas seperations as shown:
Date, Illness, Treatment, Outcome
LIST PREVIOUS SURGERIES
Note: Pl. fill the below fields using commas seperations 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.
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:
*
I understand that full disclosure is necessary to my medical safety, I have filled out this medical history to the best of my knowledge, and I have answered these questions with complete honesty to insure my health and safety.
SEND
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