Name *
Last Name *
Age *
Your Email *
Contact Information *
Home address *
Please provide all the phone numbers and the best time where we can reach you*
Profession *
Date of Birth *
Sex ManWoman
Are you? SingleMarriedPartner/RelationshipDivorced
Weight (Enter as Lbs. or kg and please indicate the units)*
Height (Example: 5' 6" or 175 cm)*
Body Mass Index (BMI) *
Desired Surgery Date:
Do you currently smoke? YesNo
Do you currently drink alcohol? YesNo
Allergic to any medication? YesNo
Allergic to surgical tape? YesNo
Allergic to latex? YesNo
Allergic to Iodine? YesNo
Allergic to any food? YesNo
If YES, please give details:
Last Menstrual Cycle date:
Do you use any hormonal contraception? YesNo
Do you have very heavy periods?YesNo
Do you suffer from infertility? YesNo
Have you had abnormally high blood glucose levels during one of your pregnancies? YesNo
List pregnancies, date and outcome (ex: full term, premature, C-section, miscarriage):
When did you start to be overweight?
Have you been diagnosed with Hepatitis B? YesNo
If YES, please specify current treatment:
Have you been diagnosed with Hepatitis C?YesNo
Have you been diagnosed with HIV?YesNo
Do you refuse Blood transfusion? YesNo
Do you have Type II Diabetes or Impaired Fasting Blood Glucose? YesNoDon't Know
Do you have High Blood Pressure? YesNoDon't Know
Do you have high blood lipids or cholesterol? YesNoDon't Know
Do you have heart disease? NoneHeart attackCardiomyopathyHeart valve diseaseHeart Failure
Other (Please specify):
Do you have a pacemaker? YesNoDon't Know
Do you have any problems with your lungs?NoneAsthmaCOPDFrequent InfectionsLung Tumor
Do you have Sleep Apnea? YesNoDon't Know Answer YES if you use CPAP or BIPAP machine
Were you ever treated for blood clots in your leg(s)? YesNo
Do you have Liver Disease? NoneFatty LiverCirrhosisLiver tumorOther
Do you have any of the following? GallstonesAcid Reflux (heartburn)Stomach Ulcers
Do you have kidney or bladder problems? NoneKidney StonesLose urine when laughKidney FailureOther
Were you ever diagnosed with Cancer? YesNo
If YES, what kind of Cancer do you have a history with?:
What year did you have Cancer?:
How did you treat your Cancer?:
Any history of seizures or epilepsy?: YesNo
If YES, what is your treatment?:
Are you diagnosed with any psychiatric illness? YesNo
Are you currently under psychiatric treatment? YesNo
If YES, please specify your treatment:
Have you had previous surgery such as? No previous surgeryAbdominal Hernia repairSmall bowel removalColon surgeryCaesareanTube LigationHysterectomyBreast augmentation/liftTummy tuck
Please give details of any previous surgery or of other surgery’s not mentioned above:
Have you had Bariatric Surgery? NoneLap BandGastric SleeveGastric BypassGastric BalloonRevision Surgery
Please specify the year you had the bariatric surgery:
Please list all the medications you are taking (dosage, frequency, reason):
Do you take anticoagulants (blood thinners) such as?NoneCoumadin (also called Warfarin)AldeparinDalterarinDanaparoid
Do you take anti-platelet drugs such as? NoneAspirin 81 mgTriflusal (Disgren)Prasugrel (Effient)Cilostazol (Pletal)Eptifibatide (Integrilin)TerutrobanTicagrelor (Brilinta)Vorapaxar (Zontivity)Tirofiban (Aggrastat)Clopidogrel (Plavix)TiclopidineHeparinAbciximab (ReoPro)Dipyridamole (Persantine)EnoxaparinOther
Is there anything related to your medical history that has not been covered?
Do you have any question for your surgeon or your medical team?
Do you have any physical limitations that require the use of prosthesis, crutches or wheelchair?
I am interested in the following surgery:Gastric SleeveGastric BypassMini Gastric BypassGastric PlicatureRevision of Previous SurgeryWill discuss options
I understand that I am requesting surgery in the private sector and that I will have to pay for this surgery. I understand that Weight Loss Surgery and its suppliers of services will collect personal information relating to me in order to prepare and carry out my surgery and to invoice me the expenses, costs and fees which correspond to it. I understand that the file containing my personal information will be preserved by Weight Loss Surgery or its suppliers of services at their offices or on their electronic servers and that their employees who require it in the performance of their duties will have access to this file.
I grant this collection and use of my personal information for this purpose. I hereby authorize Weight Loss Surgery Inc. to disclose my individually identifiable health information to the bariatric surgeons and staff of Weight Loss Surgery. This information will be used to assess my candidacy for bariatric surgery and allow the team to provide all preoperative, operative and post-operative care.
I understand that both Weight Loss Surgery Inc. and its bariatric surgeon and staff agree to abide by the NOTICE OF PRIVACY PRACTICES which is available for inspection at any time.
I have read and understand the terms.
