CONTACT INFORMATION
First Name
*
Last Name
*
Email
*
Phone
*
Gender
*
Male
Female
Age
*
Date of birth
*
Marital Status
Street Address
City
State
*
Country
*
Postal Code
Occupation
Surgeries of your interest
*
Gastric sleeve
Gastric bypass
Duodenal Switch
SADIS
Mini Bypass
Single Incision Gastric Sleeve
Bariclip
Band
Gallbladder Removal
Hernia Repair
Other
Preferred Surgery Location
Preferred Approximate Surgery Date
Current Height
What unit is this height in?:
Feet & inches
Centimeters
Current Weight
What unit is this weight in?:
Pounds (lbs)
Kilograms (kg)
Current BMI (if known)
FAMILY HISTORY
Select any medical conditions that have affected your immediate family members
Diabetes
Cancer
High Blood Pressure
Overweight
Obesity
Gallstones
Heart Disease
Any other conditions?
Additional comments
PERSONAL HEALTH HISTORY
Select any conditions that apply to you
Diabetes
High Blood pressure
Cancer
Obesity
Hearth disease
Gastric symptoms
Heart Burn or indigestion
Lupus
Fatty liver
Thyroid issues
Asthma
Sleep apnea
Gallbladder issues
Other
Mention other conditions
Hepatitis
*
HIV Possitive
*
LIFESTYLE HABITS
Do you experience shortness of breath with physical activity?
Do you exercise regularly?
How long have you been overweight?
What have you tried to do to lose weight?
Do you tend to snack between meals?
Do you see yourself as someone who eats large portion sizes?
Do you frequently consume sweets or sugary foods?
How often do you eat fast food or drink carbonated beverages?
Are there any foods or drinks that cause you digestive discomfort? Please specify.
Do you consume alcohol?
Yes
No
Do you currently smoke or use nicotine products?
Yes
No
Please list any other substance use or addictions (if applicable).
SURGICAL HISTORY
Have you had any previous bariatric procedures?
*
Yes
No
If yes, please specify the type(s) of bariatric surgery and year performed.
Please list any other surgeries you have had, and the surgery date.
Surgery 01 / Date of surgery
Surgery 02 / Date of surgery
Surgery 03 / Date of surgery
Surgery 04 / Date of surgery
Surgery 05 / Date of surgery
Surgery 06 / Date of surgery
Surgery 07 / Date of surgery
CURRENT MEDICATIONS
Provide the name and dose of all current medications and supplements.
Medication 01 / Dose
Medication 02 / Dose
Medication 03 / Dose
Medication 04 / Dose
Medication 05 / Dose
Medication 06 / Dose
Medication 07 / Dose
Medication 08 / Dose
Medication 09 / Dose
Medication 10 / Dose
Is there anything else you’d like our medical team to know to better support you?
*
I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IN THIS QUESTIONNAIRE IS TRUE, COMPLETE AND ACCURATE AS OF THE DATE HEREOF.
Signature
Clear
Date Signed
