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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.