Health Questionnaire | Doctors in the Sun

Doctors in The Sun

Weight Loss Surgery Health Form

Welcome to the first step to a lifestyle change. Please answer all the required questions.

Full Name*

First NameLast Name

Age*

Birth Date*

MonthDayYear

Marital Status

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Bariatric Surgery request*

Which surgery or surgeries are you insterested?

Surgery request*

When would you like to have your surgery?*

MonthDayYear

YesNo

If 'yes ' please list surgeries

NoYes

If you have answered yes to any of the above questions, please list the details below if appropriate:

Please list doses and the interval taken, name of medication, dose and number of times taken per day

Please indicate if any blood relative had any of the following conditions:

NoYes

Please complete the following information regarding your close relatives:
if deceased, please enter age at death and cause of death

Father

Mother

Please enter any other important family history not listed above:

Please indicate if any blood relative had any of the following conditions:

NeverRarelyModerately

How often?

NeverPreviously smokedPresently smoking

How often?

NoYes

Cups per day

NoYes

What is your job/ occupation?

NSAID's (such as ibuprofen, naprosen. eg. Advil, Aleve, etc)NSAID's (such as Vioxx and Celebrex, etc) Cortisone/ Steroids/ ACTHAnticoagulants (such as Coumadin or Warfarin) TranquilizersHypotensives (high blood pressure medicines) AspirinAcetominophen (such as Tylenol)AntibioticsAlternative or Complementary medsHerbals SupplementsDiet aids, supplements or prescriptions

PenicillinSulfa drugs

Other

MorphineCodeineDemerol

Other

Novocaine

Other

Aspirin / Empirin

Other

Tetanus antitoxin

Other

Iodine or merthiolate

EggsMilkShellfish

Other

Other drugs or medication

General

Height*

Weight*

BMI (if you know it)

NoYes

YesNoUnknown

NoYes

Gastrointestinal

NoYes

Skin

NoYes

Respiratory

NoYes

Gynecological

Not Applicable

Periods

Age started

Duration

Frequency (days)

Pregnancies

Miscarriages

Date of first day of last period

Yes

Neck

NoYes

Head-Eyes-Ears-Nose-Throat

NoYes

Cardiovascular

NoYes

Genitourinary

NoYes

Locomotor - mulculoskeletal

NoYes

Neuro - Psychiatric

NoYes

Hematologic

NoYes

Hematologic

NoYes

Are you or have you ever been under a psychiatrist's care? If yes, what was your diagnosis?

Are you or have you ever taken psychiatric medications? Please describe and for what purpose:

What do you hope to obtain from this surgery?

Date

All fields marked with * are required

General information

History of past illness

Have you ever had any of the following:

Medications currently taken

Family history

Social / personal history

Drugs recently taken - within the past six months

Allergies and sensitivities

System review

Psychological evaluation