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Free consultation

Clinic
Surgeries
Surgeons
Reviews
Gallery
Prices
FAQ
Blog
Contact us

en

sv
no
nl
da
en

Clinic
Surgeries
Surgeons
Reviews
Gallery
Prices
FAQ
Blog
Contact us

en

sv
no
nl
da
en

Patients survey sheet

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

Your full name as given in passport (required) *

Your email (required) *

What is you age *

Your height in cm (required) *

Your weight in kg (required) *

Your BMI (Body Mass Index) *

Please tell us about your diet history

How long have you been overweight?

What methods have you tried in order 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 drink carbonated beverages?

Yes
No

What foods or drinks cause you digestive problems?

Yes
No

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?

Yes
No

How many years do you smoke and how many cigarettes per day you smoke?

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

Please tell us about your personal health history

Diabetes

Yes
No

Cancer

Yes
No

Overweight

Yes
No

Obesity

Yes
No

Heart and vascular system (swelling of legs)

Yes
No

High blood pressure

Yes
No

Gastric symptoms (Indigestion, Ulcers, Reflux, Hiatal Hernia)

Yes
No

Gastroscopy

Yes
No

Do you experience shortness of breath with physical activity?

Yes
No

Respiratory system (snoring, sleep apnea)

Yes
No

Do you exercise regularly?

Yes
No

Do you have or had asthma?

Yes
No

Do you have thyroid problems?

Yes
No

Do you have any allergies? If yes, what kind of?

Have you been diagnosed with fatty liver, cirrhosis, hepatitis or any other liver disease?

Yes
No

Do you have indigestion or heart burn?

Yes
No

Do you bleed for long after tooth extraction or injury?

Yes
No

Have you ever had a blood transfusion?

Yes
No

Have you been diagnosed for lupus?

Yes
No

Have you been diagnosed HIV positive?

Yes
No

Have you had any operations/surgeries before?

Yes
No

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?

Yes
No

If so, what kind of?

Have you had any general anesthesia (narcose) before?

Yes
No

If the answer was "Yes": How did you feel during the operation and at the post-operative period?

Do you use any medicine?

Yes
No

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

(Optional) additional comments:

€

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Lithuania-based healthcare professionals trusted by hundreds of EU & UK patients each year. Our clinic offers world-class surgery only. Read more about Wellness Travels

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info@wellness-travels.com

Savanoriu pr. 284
Kaunas 49476, Lithuania

© 2012-2025 Wellness-Travels.com - safe, personal & affordable plastic surgeries & treatments abroad, EU standards, experienced doctors

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