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Bariatría Inglés
Webmaster
2017-05-21T19:53:15+00:00
Personal Information
Date
Name:
Gender:
Female
Male
Age:
Address:
Birthday:
Email:
Occupation:
Phone:
Surgery you are interested in:
Mobile:
Preferred date for surgery:
Measures
Height:
Weight:
BMI:
Family History
DIABETES:
Yes
No
CANCER:
Yes
No
HEART DISEASE:
Yes
No
OVERWEIGHT:
Yes
No
OBESITY:
Yes
No
HIGH BLOOD PRESSURE:
Yes
No
Type:
Type:
Heart Disease Type:
Other:
Family:
Type:
Personal Health History
DIABETES:
Yes
No
CANCER:
Yes
No
HEART DISEASE:
Yes
No
OVERWEIGHT:
Yes
No
OBESITY:
Yes
No
HIGH BLOOD PRESSURE:
Yes
No
Type:
Type:
Medication:
GASTRIC SYMPTOMS:
If yes, List:
Do you experience shortness of breath with physical activity?
Yes
No
Do you exercise regularly?
Yes
No
Do you have or had asthma?
Yes
No
Do you have tyroid problems?
Yes
No
Allergies:
Yes
No
Have you been diagnosed with FATTY LIVER, CIRRHOSIS, HEPATITIS or any LIVER DISEASE?
Yes
No
Do you have indigestion or heart burn?
Yes
No
Have you been diagnosed for Lupus?
Yes
No
Have you been diagnosed HIV Positive?
Yes
No
If yes, List:
If yes, explain:
List any surgeries you may have had
Surgery
Surgery
Surgery
Surgery
Date:
Date:
Date:
Date:
Reason:
Reason:
Reason:
Reason:
Current Medications
Name of Medication:
Name of Medication:
Name of Medication:
Name of Medication:
How often taken:
How often taken:
How often taken:
How often taken:
when use started:
when use started:
when use started:
when use started:
Reason:
Reason:
Reason:
Reason:
Previous meds:
List Any Major Illnesses
Illness:
Illness:
Illness:
Date:
Date:
Date:
Treatment
Treatment
Treatment
Outcome:
Outcome:
Outcome:
Diet History
How long have you been overweight?
What have you done to try to lose weight?
Are you a snacker?
Yes
No
Are you a volume eater?
Yes
No
Do you eat a lot of sweets?
Yes
No
Do you frequently eat fast food and/or do you drink carbonated beverages?
Yes
No
What foods or drinks cause you digestive problems?
Do you drink alcohol?
Yes
No
Frequency and amount:
Do you smoke?
Yes
No
Frequency and amount:
Other addictions
Yes
No
Name it:
Frequency and amount:
Please list any additional information you believe would assist in your health planning:
Submit