Your Full Name (required)

Your Email (required)

Your Age

Please fill in your Measures
Your Height
Your Weight
Your BMI

Please tell us about your diet history

How long have you been overweight?

What have you done to try to lose weight?

Are you a snacker?
YesNo
Are you a volume eater?
YesNo
Do you eat a lot of sweets?
YesNo
Do you frequently eat fast food and/or drink carbonated beverages?
YesNo
What foods or drinks cause you digestive problems?

Do you drink alcohol? If yes, please tell us how often and how much?

Do you take or have you ever taken any narcotics? If yes, please specify?

Do you smoke? If yes, please tell us how often and how much:

Do you have any other addictions? If yes, what kind of?

Please tell us about your personal health history

DiabetesYesNo
CancerYesNo
OverweightYesNo
ObesityYesNo
Heart and vascular system(swelling of legs ) YesNo
High blood pressureYesNo
Gastric symptomsYesNo
(Indigestion, Ulcers, Reflux, Hiatal Hernia)YesNo
Gastroscopy?YesNo

Do you experience shortness of breath with physical activity?
YesNo
Respiratory system (snoring, sleep apnea) YesNo
Do you exercise regularly?
YesNo
Do you have or had asthma?
YesNo
Do you have thyroid problems?
YesNo
Do you have any allergies? If yes, what kind of?

Have you been diagnosed with fatty liver, cirrhosis, hepatitis or any other liver disease?
YesNo
Do you have indigestion or heart burn?
YesNo
Do you bleed for long after tooth extraction or injury?
YesNo
Have you ever had a blood transfusion?
YesNo
Have you been diagnosed for lupus?
YesNo
Have you been diagnosed HIV positive?
YesNo
Have you had any operations/surgeries before?
YesNo
If the answer was "Yes":
What kind of operation(s) were performed and when?

Did you have any complications during the operation or at the post-operative period?YesNo
If so, what kind of?

Have you had any general anesthesia (narcose) before?
YesNo
If the answer was "Yes":
How did you feel during the operation and at the post-operative period?

Do you use any medicine?
YesNo
If the answer was "Yes", what kind of medicine do you take/How often taken/Reason?

Please list any major illnesses you have had if any?

Please list any additional information you believe would assist in your health planning

Preferred type of bariatric surgery and date.