Health Questionnaire

All your information will be used for medical history purposes only.
There is no obligation by filling out this Health Questionnaire. Terms and Conditions only apply upon booking your surgery if you decide to do so.

    Personal Information

    Today's Date *

    MM/dd/yyyy

    Personal Information

    Full Name *
    E-mail *
    Phone Number *
    Date of Birth *
    Age *
    Address *
    Gender *
    Occupation (Optional)
    BMI

    Height (Feet) *
    Height (Inches) *
    Weight (Lbs.) *
    Surgical Preferences
    Have You Had a Previous Weight Loss Procedure? *
    Which Weight Loss Procedure? *
    Past Procedure Date *
    Open Incision or Laparoscopic? *
    What Surgery Are You Interested In? *
    Desired Surgery Date (Optional)
    Referred by (Optional)
    Ongoing Medical Conditions
    Have you been diagnosed with Hepatitis? *

    Hepatitis Type *

    Has Hepatitis Been Treated? *
    Have you been diagnosed with HIV? *

    HIV since? *

    Has HIV been treated? *
    Refuse Blood Transfusions? *

    Why you refuse blood transfusions?*
    Allergies? *

    Type of Allergies *

    Allergic Reactions? *
    Previous Surgery to treat Acid Reflux/GERD (Nissen Fundoplication)? *

    Procedure Name *

    Procedure date *
    Diagnosed with a Hiatal Hernia that hasn't been repaired? *
    Medication Information
    Are you taking any Medication? *

    Include all Prescriptions and Over-the-Counter Medications *
    Illness History
    Do you have any Illnesses? *

    Include all Conditions, Diseases, Syndromes or Current Illnesses. *
    Surgery History
    Have you had any Surgical Procedures? *

    (Not including any previous weight loss procedure)

    Include all Surgical Procedures. *
    Auto Immune System
    Do you have Rheumatoid Arthritis? *

    Treatment for Rheumatoid Arthritis*
    Do you have a Skin Rash or Hives? *

    Length of Time for Skin Rash or Hives*

    Treatment for Skin Rash or Hives*
    Cardiovascular System
    Cardiovascular Problems or Symptoms? (Stroke, high blood pressure, heart attack, heart disease, embolism, blood clotting, anemia, bleeding tendency, etc.) *

    Have You Ever Had a Stroke? *

    Have You Ever Had a Stroke? *

    Stroke Details *

    History of High Blood Pressure? *

    Length of Time for High Blood Pressure *

    Treatment for High Blood Pressure *

    History of Heart Attack? *

    Date of Heart Attack *

    Treatment for Heart Attack *

    History of Heart Disease? *

    Which Heart Disease(s)? *

    Treatment for Heart Disease(s) *

    History of Embolism? *

    Date of Heart Embolism *

    Heart Embolism Diagnosis *

    Treatment for Heart Embolism *

    History of Anemia? *

    Length of Time for Anemia *

    Treatment for Anemia *

    History of Bleeding Tendency/Disorder? *

    Length of Time *

    Diagnosis *

    Treatment *
    Endocrine System
    Are You Diabetic? *

    Diabetic Type*

    How is Diabetes Controlled?*
    Hepatic System
    Liver System problems or symptoms? (ie. fatty liver, cirrhosis, liver disease, etc.) *

    Fatty Liver? *

    Cirrhosis? *

    Liver Disease? *
    Gastrointestinal System
    Gastrointestinal System Problems or Symptoms? (ie. diverticulitis, Crohn's disease, ulcerative colitis, ulcers, etc.) *

    Diverticulitis? *

    Crohn's Disease? *

    Ulcerative Colitis? *

    History of Ulcers? *
    Have You Ever Experienced Abdominal Trauma? *

    When? *

    What Caused Abdominal Trauma? *

    How was it Treated? *
    Nervous System
    Anxiety? *

    Length of Time Having Anxiety *

    Treatments for Anxiety *
    Paralysis? *

    Length of Time Having Paralysis *

    Treatments for Paralysis *
    Loss of Consciousness? *

    Length of Time *

    Treatment *
    Convulsions or Seizures? *

    Length of Time Having Convulsions or Seizures *

    Treatments for Convulsions or Seizures *
    Diet and Intake History
    How often do you eat Sweets per week? *
    How often do you eat Fast Food per week? *
    How often do you drink Soda per week? *
    Drink Alcohol? *
    Do you Smoke? *
    Do you use any other Nicotine Products? *

    Other Nicotine Products? *
    Ingest Caffeine? *
    Comments
    Anything related to your medical history that has not been covered? *

    Please indicate medical history that has not been covered *
    Any questions for your surgeon? *

    Please indicate any questions or comments*
    Terms and Conditions *
    1. All information that you are required to provide with this Health Questionnaire, as well as any other medical information thereafter, is required to be truthful, complete, and accurate. If it is not accurate, the surgeon can cancel your surgery resulting in the loss of security deposit and all monies paid for the surgery.
    2. It is imperative that the height and weight reported on the Health Questionnaire be accurate. ALL patients are weighed and measured before surgery. If the BMI (Body Mass Index) at the time of surgery does not accurately reflect the height and weight reported on the Health Questionnaire, the surgeon(s) may exercise their right to forego the surgical procedure and any deposit made will be forfeited.
    3. If you decide to schedule your surgery, we reserve the right to be able to contact you via phone, email, and/or text. Any previous settings for those communication methods to be disabled will be overridden.

    Signature (Gently tap on signature pad prior to signing) *

    By Signing Electronically You Agree to the Terms: I understand that full disclosure is necessary to my medical safety. I acknowledge that I have provided all of my personal and medical history accurately.