subject_line
Contact Information
First Name
*
Middle
Last Name
*
Gender
Male
Female
Age
Birth Date
+
Marital Status
Single
Married
Separated
Divorced
Widowed
Street Address
Street Address 2
City
State/Province
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Zip Code
Daytime Phone
Mobile Phone
*
Email address
*
Confirm Email address
*
Personal Information
Occupation
Surgeries you are interested in:
Lap Band
Single Incision Laparoscopic Surgery
Revision Surgery
Gastric Sleeve Surgery
Gastric Bypass Surgery
Duodenal Switch
Bariclip
Location of Surgery
Guadalajara
Tijuana
Puerto Vallarta
Preferred Date of Surgery
+
Height:
Weight:
BMI
Family History
Diabetes
Yes
No
Diabetes Type / Info:
Cancer
Yes
No
Cancer Type / Info:
Overweight
Yes
No
Obesity
Yes
No
Heart Disease
Yes
No
Heart Disease Type / Info:
High Blood Pressure
Yes
No
High Blood Pressure Type / Info:
Other
Yes
No
Other Type / Info:
Personal Health History
Diabetes
Yes
No
Diabetes Type / Medication:
Cancer
Yes
No
Cancer Type:
Overweight
Yes
No
Obesity
Yes
No
Heart Disease
Yes
No
Heart Disease Type / Medication:
High Blood Pressure
Yes
No
High Blood Pressure Medication:
Gastric Symptoms
Yes
No
Please list Gastric Symptoms:
Do you experience shortness of breath with physical activity?
Yes
No
Do you exercise regularly?
Yes
No
Frequency of Exercise:
7 days a week
5 days a week
4 days a week
3 days a week
2 days a week
1 day a week
Do you have, or have you had asthma?
Yes
No
Do you have thyroid problems?
Yes
No
Do you have allergies?
Yes
No
Please list your allergies:
Have you been diagnosed with fatty liver, cirrhosis, Hepatitis or any other liver disease?
Yes
No
If Yes, please explain:
Do you have indigestion or heartburn?
Yes
No
Have you been diagnosed with Lupus?
Yes
No
Have you been diagnosed HIV positive?
Yes
No
Current Medications
Name of Medication (1)
Frequency (1)
Start Date (1)
+
Reason (1)
Name of Medication (2)
Frequency (2)
Start Date (2)
+
Reason (2)
Name of Medication (3)
Frequency (3)
Start Date (3)
+
Reason (3)
Name of Medication (4)
Frequency (4)
Start Date (4)
+
Reason (4)
Name of Medication (5)
Frequency (5)
Start Date (5)
+
Reason (5)
Name of Medication (6)
Frequency (6)
Start Date (6)
+
Reason (6)
Name of Medication (7)
Frequency (7)
Start Date (7)
+
Reason (7)
Previous Medications:
List of Major Illnesses
Illness (1)
Date (1)
+
Treatment (1)
Outcome (1)
Illness (2)
Date (2)
+
Treatment (2)
Outcome (2)
Illness (3)
Date (3)
+
Treatment (3)
Outcome (3)
Illness (4)
Date (4)
+
Treatment (4)
Outcome (4)
List all Surgeries
Surgery (1)
Date (1)
+
Reason (1)
Surgery (2)
Date (2)
+
Reason (2)
Surgery (3)
Date (3)
+
Reason (3)
Surgery (4)
Date (4)
+
Reason (4)
Surgery (5)
Date (5)
+
Reason (5)
Have you had previous Bariatric Surgery?
Yes
No
List all Bariatric Surgeries
Surgery (1)
Date (1)
+
Reason (1)
Surgery (2)
Date (2)
+
Reason (2)
Surgery (3)
Date (3)
+
Reason (3)
Surgery (4)
Date (4)
+
Reason (4)
How long have you been overweight?
2 yrs
4 yrs
6 yrs
8 yrs
10 yrs
Over 10 yrs
What have you tried to do to lose weight?
0/255 characters
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 do you drink carbonated beverages?
Yes
No
What foods or drinks cause you digestive problems?
Do you ever drink alcohol?
Yes
No
Frequency
Multiple times a day
Once a day
Once every other day
Three times a week
Twice a week
Once a week
Amount
1 drink
2 drinks
3 drinks
4 drinks
5 drinks
6 drinks
Do you ever smoke?
Yes
No
Frequency
Multiple times a day
Once a day
Once every other day
Three times a week
Twice a week
Once a week
Amount
1 cigarette
2 cigarettes
3 cigarettes
4 cigarettes
5 cigarettes
6 cigarettes
7 cigarettes
Please list other addictions
0/255 characters
Frequency
Multiple times a day
Once a day
Once every other day
Three times a week
Twice a week
Once a week
Please list any additional information you believe would assist in your health planning:
0/255 characters
Confirmation
I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IN THIS QUESTIONNAIRE IS TRUE, COMPLETE AND ACCURATE AS OF THE DATE HEREOF.
Type your Full Name: First, Middle and Last in the field below
to confirm you agree with the statement
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Date of Signature:
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to prove a person filled out this form.
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