CONTACT INFORMATION
First Name
*
Last Name
*
Email
*
Phone
*
Gender
*
Male
Female
Age
*
Birthdate
Street Address
City
State
*
Country
*
Postal Code
Surgery of Interest
Choose one or more options
Preferred Surgery Location
Preferred 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)
PERSONAL HISTORY
Select the conditions that apply to you
Choose one or more options
Hepatitis
*
HIV Possitive
*
Additional comments or other conditions
What have you tried to do to lose weight?
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. (SURGERY/DATE OF SURGERY)
Please list any other surgeries you have had, and the surgery date. (SURGERY/DATE OF SURGERY)
CURRENT MEDICATIONS
List ALL current medications and supplements (MEDICATION/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
