Medical History

MaleFemale

Where do you live?United StatesCanadaMexicoOther

Native Language?EnglishSpanish

Emergency contact

Have you ever smoked?NoYes

If you answered yes, please tell us the quantity

and since what year

Do you drink alcohol?NoYes

If yes, how frequently do you have a drink?

Do you know when you would like to have the surgery?

Do you prefer a specific type of surgery?SurgeryApendicitisColelitiasisColitisColonDiverticulitisConstipationGastritisHemorrhoidsHerniasHernia HiatalGallbladderGastric SleeveGastric BypassDuodenal Switch

Have you ever had weight loss surgery in the past?NoYes

If yes, please tell us about this procedure

Have you seen a doctor in the past about weight loss surgery?NoYes

Please list all medications and the current dosage that you taking:

Please list all medical conditions you have:

Have you ever had an abdominal surgery, endoscopy, or plastic surgery?NoYes

Have you undergone anesthesia in the past? (local, epidural or general)?NoYes

Have you been pregnant? How many times? Did you deliver via cesarean section (C-section)?

Do you have regular or irregular menstrual periods?RegularIrregular

Do you suffer from acid reflux?NoYes

Do you have gastritis?NoYes

Do you have high blood pressure?NoYes

Do you have diabetes?NoYes

Do you have high cholesterol?NoYes

Do you have sleep apnea?NoYes

Do you use a C-Pap or B-Pap machineNoYes

Please list all allergies:

Do you currently, or have you ever suffered from depression?NoYes

If yes, are you currently under treatment?NoYes

Do you have a history of heart problems? (attack, angina, arrhythmia)NoYes

Do you have joint pain or joint injuries or conditions?NoYes

Do you have swelling in your legs, ankles, or have varicose veins?NoYes

Do you have asthma, Bronchitis, or Chronic Cough?NoYes

Do you suffer from thyroid problems?NoYes

Do you have Ulcerative Colitis or Crohns Disease?NoYes

Do you have problems with your liver or gallbladder, or pancreatitis?NoYes

Have you ever had cancer or tumors?NoYes

Please describe your typical diet: