Mexico Bariatric Services
Med Tourism Co. LLC, Medical Tourism, Plano, TX
Med Tourism Co. LLC, Medical Tourism, Plano, TX
+1-800-661-2126
info@mexicobariatricservices.com

Bariatric Questionnaire

PERSONAL DETAILS

Desired Destination
Desired Medical Procedure
Name of the Surgeon:
First Name:*
Last Name:*
Address:*
Postcode:*
Telephone No (Home):*
Your E-Mail Address*
Telephone No (Business):
Mobile No:
Date Of Birth:*
Age:*
Occupation:*
Language Spoken:*
Proposed Surgical Date*
Do you have a passport?*
Yes   No

CONTACT PERSONS

This information is often vital to us if we need to contact you urgently. Occasionally people move / have new phone numbers & do not let us know.

*Name:
*Relationship:
*Address:
*Telephone No (Home):
Telephone No (Business):

PRIMARY HEALTHCARE PROVIDER

Name:
How long he/she has been treating you?
Conditions Treated:
Telephone:
Any other physician/s?
Address:
Telephone:

SOCIAL PROFILE

FAMILY STRUCTURE


*Marital Status:
Married   Single
If married or previously married, what is your current status?
Divorced   Partner
Have Children?
Yes   No
If yes, Please specificy Number and Age

WEIGHT HISTORY


Please indicate your weight at following times. Please indicate whether you consider your weight was below average, average, above average or very heavy in relevant boxes.
 *W = Weight   Below 
 Average 
 Average 
 Weight 
 Above 
 Average 
 Very 
 Heavy 
Birth *W
*W at beginning of high school (10-12 yrs)
*W at end of high school (15-18 years)
*W at time of commencing work (21 years)
*W at time of marriage (if applicable)
*Current Weight
*Height
*BMI
*Current Body Shape
 Apple Shape   Pear Shape
 Other  Don't Know
if other, please describe:
*Waist Circumference

WEIGHT LOSS HISTORY

PAST ATTEMPTS


*Weight Watchers
Yes   No
if yes, Duration?
*Jenny Craig/Nutrisystem/Gloria Marshall etc
Yes   No
If yes, Duration?
*Fad diets
Yes   No
if yes, Duration?
*Appetite suppressants
Yes   No
if yes, Duration?
*Any other drug treatment
Yes   No
If yes, Duration?
*Details of any other weight loss measures (including surgical):
*Were there any particular events that lead to significant weight gain:
Yes   No
If yes, please explain:

SURGICAL HISTORY

Please give details of any past operations:

PERSONAL MEDICAL HISTORY

Have you ever suffered with any of the following health problems?

*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?
*Back pain
Yes   No
if yes, Details?
*Kidney or urinary disorder
Yes   No
if yes, Details?
*Neurological
Yes   No
if yes, Details?
*Psychological/nervous disorder
Yes   No
if yes, Details?
*Gallstones
Yes   No
if yes, Details?
*Reflux or heartburn
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?
*Thrombosis or clotting 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?
Please give details of any major illnesses/problems

FAMILY MEDICAL HISTORY

Do you have a family history of any of the following and if so, please indicate:
   Parent   Sibling 
 /Child 
 Other 
 Relatives 
 No Family 
 History 
 Don't 
 Know 
*Diabetes
*Heart Disease
*Hypertension
*Gout
*Gallstones
*Obesity
*Snoring
*Asthma
*Allergies
*Hay fever
*Dermatitis 
/Eczema 
*High 
Cholesterol 
*Osteoporosis
*Hip fractures

*ALLERGIES?

Yes   No
If yes, please give details (foods, medications, dressings & any other):

ALCOHOL

*Do you drink alcohol?
Never   Rarely   Regularly
How many standard glasses do you drink per day?
How many days do you drink per week?
What do you drink?
Beer   Wine   Spirits

SMOKING

*Do you smoke?
Yes   No   Never
If yes: how many per day?
Have you smoked in the past?
Yes   No
If so, how many per day?
If so, for how many years?
If so, when did you stop smoking?

SLEEP HISTORY

*How many hours sleep do you get a night?
*Is there any thing else that keeps you awake at night?
Yes   No
if yes, Details?

SYMPTOMS OF SLEEP APNEA

How often do you Snore?
Never
Rarely
Occasionally
Frequently
Always
Do you wake during the night with a choking feeling?
Never
Rarely
Occasionally
Frequently
Always
How often would you sleep more than 8 hours in total in a 24 hour period?
Never
Rarely
Occasionally
Frequently
Always
Do you feel sleepy during the day?
Never
Rarely
Occasionally
Frequently
Always
Has anyone noticed that you momentarily stop breathing during your sleep?
Never
Rarely
Occasionally
Frequently
Always
How often do you doze off or fall asleep while driving?
Never
Rarely
Occasionally
Frequently
Always

EMPLOYMENT

*Are you currently employed?
Yes   No
Current Employment:
Are you full-time, part-time or casual?
Full time  Part Time
Casual
If you are unemployed, what is the reason?
*Are you actively looking for work?
Yes   No
*Has your weight made it difficult to find employment?
Yes   No
If employed, please state what level of activity your job involves:
Little (sedentary job)
Moderately active
Very active (Labouring, etc.)

MEDICATIONS

Please indicate whether you are now or have previously taken any of the following medications. If yes, please state the name of the medication and how long you have been or were taking it.

*Medication for psychiatric disorder
Yes   No
if yes, Details?
*Migraine medication
Yes   No
if yes, Details?
*Medications to assist weight loss
Yes   No
if yes, Details?
*Drugs for epilepsy
Yes   No
if yes, Details?
*Drugs for asthma or breathing
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?
*Please list in detail all medications that you have used in the last 12 months. Please include any dietary supplements, cremes, eye drops, etc.

BREATHING HISTORY

*Does being at work ever make your chest tight or wheezy?
Yes   No
if yes, Details?
*Have you ever had asthma?
Never
Current
In the past
Don't know

GASTRO ESOPHAGEAL REFLUX / INDIGESTION

*Do you have a history of heartburn or indigestion?
Yes   No
Details
If yes, how often do you have reflux during the day?
Many times a day
Everyday
Most days
Most weeks
Occasionally
*Do you suffer heart burn / indigestion during the night?
Yes   No
If so how often
Many times a day
Everyday
Most days
Most weeks
Occasionally
What aggravates or causes your reflux?
*Do you have difficulty swallowing?
Yes   No
if yes, Details?
*Does food ever get stuck?
Yes   No
if yes, Details?
*Does food or fluid reflux into the mouth?
Yes   No
if yes, Details?
*Do you vomit with reflux?
Yes   No
if yes, Details?
*Do you suffer from recurrent sore throats?
Yes   No
if yes, Details?
*Do you suffer from a hoarse voice?
Yes   No
if yes, Details?
*Do you suffer from a regular cough at night?
Yes   No
if yes, Details?
Please list any treatments you may use for reflux / heartburn or indigestion

OB/ GYN:

Please, specify pregnancies, births, abortions:


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Med Tourism Co LLC (www.MedicalTourismCo.com) connects patients to one of the best hospitals in the world. Med Tourism Co LLC 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.

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