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

Bariatric Questionnaire

PERSONAL DETAILS

Desired Destination:
Desired Medical Procedure:
Name of the Surgeon:
First Name:*
Last Name:*
Primary Contact No:*
Secondary Contact No:
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:*
Current Weight:*
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.

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