Bariatric Questionnaire
PERSONAL DETAILS
Desired Destination:
Desired Medical Procedure:
Name of the Surgeon:
First Name:*
Last Name:*
Primary Contact No:*
Secondary Contact No:
Profession:
Address & Country:*
Zip/Postal Code:*
Your E-Mail Address:*
Date of Birth:*
Language Spoken:*
Proposed Surgical Date:
EMERGENCY CONTACT
Name:*
Relationship:*
Telephone No (Home):*
Telephone No (Business):
PRIMARY HEALTHCARE PROVIDER
Name:
Conditions Treated:
HEIGHT & WEIGHT
Current Height (cm):*
Current Weight (kg):*
Overweight since when?
Current Body Shape:
Apple
Pear
Other
PREVIOUS BARIATRIC PROCEDURES
Any previous bariatric surgery:*
Yes
No
If yes, which surgery?
PERSONAL MEDICAL HISTORY
Have you suffered from any of the following?
Diabetes:*
Yes
No
If yes, details?
Diabetes while pregnant:*
Yes
No
If yes, details?
Asthma:*
Yes
No
If yes, details?
Respiratory/Breathing problems:*
Yes
No
If yes, details?
Arthritis or joint pain:*
Yes
No
If yes, details?
Kidney or urinary disorder:*
Yes
No
If yes, details?
Neurological disorder:*
Yes
No
If yes, details?
Psychological/nervous disorder:*
Yes
No
If yes, details?
Gallstones:*
Yes
No
If yes, details?
Thrombosis or clotting disorder:*
Yes
No
If yes, details?
Gastric or duodenal ulcer:*
Yes
No
If yes, details?
Hepatitis or liver disease:*
Yes
No
If yes, details?
High blood pressure:*
Yes
No
If yes, details?
Heart disease:*
Yes
No
If yes, details?
High cholesterol:*
Yes
No
If yes, details?
Anemia or bleeding disorder:*
Yes
No
If yes, details?
Varicose veins or leg swelling:*
Yes
No
If yes, details?
Eczema or skin condition:*
Yes
No
If yes, details?
Hayfever or Rhinitis:*
Yes
No
If yes, details?
Back pain:*
Yes
No
If yes, details?
Any other?
ALLERGIES/ SMOKING/ ALCOHOL/ DRUGS
Recreational drug use:*
Yes
No
If yes, please give details:
Do you smoke?*
Yes
No
Never
Any allergies:*
Yes
No
If yes, please give details (foods, medications,etc):
Do you drink alcohol?*
Never
Rarely
Regularly
SLEEP APNEA
Do you have sleep apnea?*
Yes
No
Do you use CPAP machine?*
Yes
No
EMPLOYMENT
Are you currently employed?
Yes
No
Current Employment:
If employed, please state what level of activity your job involves:
Little (sedentary job)
Moderately active
Very active (labouring, etc.)
MEDICATIONS
Have you ever taken any of the following medications?
Migraine:*
Yes
No
If yes, details?
Weight loss assistance:*
Yes
No
If yes, details?
Epilepsy:*
Yes
No
If yes, details?
Asthma or breathing:*
Yes
No
If yes, details?
Psychiatric disorder:*
Yes
No
If yes, details?
Hormones, e.g., the pill:*
Yes
No
If yes, details?
HRT:*
Yes
No
If yes, details?
Cortisone:*
Yes
No
If yes, details?
Blood thinners:*
Yes
No
If yes, details?
Medications taken in last 12 months (include any dietary supplements, cremes, eye drops, etc.):
GASTRO ESOPHAGEAL REFLUX/ INDIGESTION
History of heartburn, acid reflux or indigestion:*
Yes
No
Please list any related treatments:
OB/ GYN:
Pregnancies, births, abortions:
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Mexico Bariatric Services (www.MexicoBariatricServices.com), a unit of Med Tourism Co LLC (www.MedicalTourismCo.com), connects patients to the best hospitals in the world. Mexico Bariatric Services does not provide advice on medical treatments nor makes claims or guarantees on the outcome of any medical treatment or surgery. Before making any medical related decision you must thoroughly discuss & seek advice from a qualified medical professional.
I have read the above statement,
Terms & Conditions
&
Health Privacy & Confidentiality Statement
on the Mexico Bariatric Services Website.