Bariatric Medical Questionnaire

Personal Information (*We do not share this information)

Gender

Emergency Contact

Medical

*If unsure, the surgeon will suggest the right surgery as per your needs.

Height and Weight

Since when have you been overweight?

Bariatric Surgery History

Have you undergone any bariatric surgery earlier?

PERSONAL MEDICAL HISTORY

Diabetes
Diabetes while pregnant
Asthma
Respiratory/Breathing problems
Arthritis or joint pain
Kidney or urinary disorder
Neurological disorder
Psychological/nervous disorder
Gallstones
Thrombosis or clotting disorder
Gastric or duodenal ulcer
Hepatitis or liver disease
High blood pressure
Heart disease
High cholesterol
Anemia or bleeding disorder
Varicose veins or leg swelling
Eczema or skin condition
Hayfever or Rhinitis
Back pain
Any other medical history?

Allergies/ Smoking/ Alcohol/ Drugs

Recreational drug use
Do you smoke?
Any allergies
Do you drink alcohol?

Sleep Apnea

Do you have sleep apnea?
Do you use CPAP machine??

Medication

Have you ever taken medications for any of the following?

Migraine
Weight loss assistance:
Epilepsy
Asthma or breathing:
Psychiatric disorder
Hormones, e.g., the pill:
HRT
Cortisone:
Blood thinners
Have you had any infectious diseases before?
History of heartburn, acid reflux or indigestion
Medications taken in last 12 months (include any dietary supplements, cremes, eye drops, etc.)
Please list any other related treatments (if any).

OB/GYN

Pregnancies, births, abortions details (if any).
How did you hear about us?

Mexico Bariatric Services (www.mexicobariatricservices.com) connects patients to one of 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.