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Personal Information

Date
Name:
Gender:
Age:
Address:
Birthday:
Email:
Occupation:
Phone:
Surgery you are interested in:
Mobile:
Preferred date for surgery:

Measures

Height:
Weight:
BMI:

Family History

DIABETES:
CANCER:
HEART DISEASE:
OVERWEIGHT:
OBESITY:
HIGH BLOOD PRESSURE:
Type:
Type:
Heart Disease Type:
Other:
Family:
Type:

Personal Health History

DIABETES:
CANCER:
HEART DISEASE:
OVERWEIGHT:
OBESITY:
HIGH BLOOD PRESSURE:
Type:
Type:
Medication:
GASTRIC SYMPTOMS:
If yes, List:
Do you experience shortness of breath with physical activity?
Do you exercise regularly?
Do you have or had asthma?
Do you have tyroid problems?
Allergies:
Have you been diagnosed with FATTY LIVER, CIRRHOSIS, HEPATITIS or any LIVER DISEASE?
Do you have indigestion or heart burn?
Have you been diagnosed for Lupus?
Have you been diagnosed HIV Positive?
If yes, List:
If yes, explain:

List any surgeries you may have had

Surgery
Surgery
Surgery
Surgery
Date:
Date:
Date:
Date:
Reason:
Reason:
Reason:
Reason:

Current Medications

Name of Medication:
Name of Medication:
Name of Medication:
Name of Medication:
How often taken:
How often taken:
How often taken:
How often taken:
when use started:
when use started:
when use started:
when use started:
Reason:
Reason:
Reason:
Reason:
Previous meds:

List Any Major Illnesses

Illness:
Illness:
Illness:
Date:
Date:
Date:
Treatment
Treatment
Treatment
Outcome:
Outcome:
Outcome:

Diet History

How long have you been overweight?
What have you done to try to lose weight?
Are you a snacker?
Are you a volume eater?
Do you eat a lot of sweets?
Do you frequently eat fast food and/or do you drink carbonated beverages?
What foods or drinks cause you digestive problems?
Do you drink alcohol?
Frequency and amount:
Do you smoke?
Frequency and amount:
Other addictions
Name it:
Frequency and amount:
Please list any additional information you believe would assist in your health planning: