Bariatric Virtual Consultation - VIDA Wellness and Beauty

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Please fill out the form below to get started!

Personal Information
Name
First
Last Name
First
Gender:
- Female
- Male
Age:
Height:*
Weight:*
Pregnancies, if yes, how many?
Birthday:
Email:
Phone:
Occupation:
Personal Health History
DIABETES:
- Yes
- No
Type:
Medication:
CANCER:
- Yes
- No
Type:
HEART DISEASE:
- Yes
- No
OVERWEIGHT:
- Yes
- No
OBESITY:
- Yes
- No
HIGH BLOOD PRESSURE:
- Yes
- No
GASTRIC SYMPTOMS:
If yes, List:
Do you experience shortness of breath with physical activity?
- Yes
- No
Do you exercise regularly?
- Yes
- No
Do you have or had asthma?
- Yes
- No
Do you have tyroid problems?
- Yes
- No
Allergies:
- Yes
- No
If yes, List:
Have you been diagnosed with FATTY LIVER, CIRRHOSIS, HEPATITIS or any LIVER DISEASE?
- Yes
- No
If yes, explain:
Do you have indigestion or heart burn?
- Yes
- No
Have you been diagnosed for Lupus?
- Yes
- No
Have you been diagnosed HIV Positive?
- Yes
- No
Have you had any gastro-instenstal surgery?
- Yes
- No
Please list and current medication, supplements, or other substances*

List Any Major Illnesses

Illness:	Date:	Treatment	Outcome:

Diet History
What have you done to try to lose weight?
Are you a snacker?
- Yes
- No
Are you a volume eater?
- Yes
- No
Do you eat a lot of sweets?
- Yes
- No
Do you drink alcohol?
- Yes
- No
Frequency and amount:
Do you smoke?
- Yes
- No
Frequency and amount:
Other addictions
- Yes
- No
which ones?
Frequency and amount:
Please list any additional information you believe would assist in your health planning:
Comments
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