Name* (required)

E-mail* (required)

Confirm your E-mail* (required)

Type of Surgery ORBERA - Intragastric BalloonSPATZ - Intragastric BalloonGastric bandGastric sleeveGastric Bypass - 1 AnastomosisGastric Bypass - Roux Y

FAMILY STRUCTURE:

MarriedSingleDivorcedCouple/Relationship

CURRENT OCCUPATION

PAST ATTEMPTS OF WEIGHT LOSS

Results

Details of any other types of weight loss (including surgical)

FAMILY BACKGROUND

Mention all important illnesses your close relatives suffer from (Parents, Brothers, Uncles, Grandparents, Children).
DiabetesHypertensionCancerObesityCholesterolCardiac DiseasesAsthmaDropGallstones

If any, please give detail

PERSONAL BACKGROUND

ALLERGIES (including food, medications, etc.): YesNo

If any, please give detail

ALCOHOL

It is evident that alcohol consumption can increase some risk factors that lead to heart disease and stroke. In fact, avoiding alcohol can reduce the mortality associated with these serious conditions.

Frequency: NeverRarelyRegularly

Usually, when do you drink?
Social eventsPartiesWith mealsBefore / after eatingWeekends

TOBACCO

Do you smoke? YesNoNunca

If yes, how many cigarettes a day?

Have you smoked in the past? YesNoNunca

If yes, how many cigarettes a day?

PERSONAL MEDICAL BACKGROUND

Have you ever suffered from any of the following health problems:

Please give details of any major illnesses/problems

SYMPTOMS OF SLEEP APNEA

How likely is it that you would fall asleep, doze off or just feel tired in the following situations? This is referring to your current life. Even if you have not done some of these things recently, try to see how they would affect you.

Use the following table to choose the most appropriate option for each situation:

MEDICATIONS

Please list all medications that you have taken in the last 12 months.

RESPIRATORY HISTORY

ASTHMA

Have you ever had to spend a night in the hospital for respiratory problems or asthma?
NeverCurrentlyIn the pastDon't know

Have you had asthma? (select one of the following)
YesNo
If it has, please indicate when:

In the last 12 months, have you visited an emergency doctor or went to the emergency room of a hospital do to asthma or respiratory problems?
YesNo
Explain:

In the past 12 months, have you taken prednisolone do to asthma or breathing problems.
YesNo
Explain:

In the last 12 months, have you missed work or school do to asthma or respiratory problems.
YesNo
Explain:

COUGH AND SHORTNESS OF BREATH:

Do you suffer from a cough? YesNo

Do you normally cough with phlegm? YesNo

At the moment of making any type of effort, do you have shortness of breath? YesNo

Do you feel shortness of breath when walking on a flat surface? YesNo

Do you lack of air when you are walking uphill or doing housework? YesNo

ACTIVITY LEVEL

What type exercise do you perform on a regular basis?

How many sessions of exercise (walking, sports, etc.) do you implement per week for more than 30 minutes at a time?

How do you feel when you exercise? Please indicate on the scale, when 0 is "Terrible" and 10 is "Excelt" 012345678910

GASTRO OESOPHAGEAL REFLUX / INDIGESTION

Do you have a history of heartburn or indigestion? YesNo
Describe

If yes, how often do you have reflux during the day?
Many times, a dayEverydayAlmost every dayAlmost every weekOccasionally

Do you suffer from heart burn / indigestion during the night? How often?
Many times, a dayEverydayAlmost every dayAlmost every weekOccasionally

What aggravates or causes your reflux? Describe

Do you have difficulty swallowing? YesNo
Describe:

Does food ever get stuck? YesNo
Describe:

Does food or fluid cause stomach reflux? YesNo
Describe:

Does reflux make you vomit? YesNo
Describe:

Do you suffer from recurring sore throats? YesNo
Describe:

Do you suffer from a hoarse voice? YesNo
Describe:

Do you cough at night on a regular basis? YesNo
Describe:

Please list any treatments you may use for reflux / heartburn or indigestion

SURGICAL BACKGROUND

Please give full detail of any surgeries that you had in the past: