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Home » Bariatric surgery survey

We respect our patients’ privacy and confidentiality and guarantee that your personal information will not be misused.

Bariatric surgery survey

    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.

    If you would like to know how we process & secure your personal data – read our Privacy policy or simply contact us.

    Get a quote & more info

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