Online Bariatric Application

    Name* (required)

    City
    Country
    State

    E-mail* (required)

    Confirm your E-mail* (required)

    Sex
    Home number
    Mobile number

    Type of Surgery

    Age (required)
    Weight (required)
    Height (required)


    FAMILY STRUCTURE:

    CURRENT OCCUPATION


    PAST ATTEMPTS OF WEIGHT LOSS

    Past diets
    Length of time

    Results

    Appetite suppressants
    Length of time

    Other types of medication
    Length of time

    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).

    If any, please give detail


    PERSONAL BACKGROUND

    ALLERGIES (including food, medications, etc.):

    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:

    Usually, when do you drink?

    TOBACCO

    Do you smoke?

    If yes, how many cigarettes a day?

    Have you smoked in the past?

    If yes, how many cigarettes a day?

    How many years?
    When did you quit smoking?


    PERSONAL MEDICAL BACKGROUND

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

    Diabetes:
    Describe
    Diabetes while pregnant:
    Describe
    Asthma:
    Describe
    Respiratory/Breathing problems:
    Describe
    Arthritis or joint pain:
    Describe
    Back pain:
    Describe
    Kidney or urinary disorder:
    Describe
    Neurological:
    Describe
    Psychological/nervous disorder:
    Describe
    Gallstones:
    Describe
    Reflux or heartburn:
    Describe
    Gastric or duodenal ulcer:
    Describe
    Hepatitis or liver disease:
    Describe
    High blood pressure:
    Describe
    Heart disease:
    Describe
    High cholesterol:
    Describe
    Anaemia or bleeding disorder:
    Describe
    Thrombosis or clotting disorder:
    Describe
    Varicose veins or leg swelling:
    Describe
    Eczema or skin condition:
    Describe
    Hayfever or Rhinitis:
    Describe

    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:

    Situation [0]
    Never fall asleep
    [1]
    Slight chance of falling asleep
    [2]
    Moderate chance of falling asleep
    [3]
    High chance of falling asleep
    Read and be seated Yes Yes Yes Yes
    Watch TV Yes Yes Yes Yes
    Sitting inactive in a public place (theater or meeting) Yes Yes Yes Yes
    As a passenger in a car traveling an hour without stopping. Yes Yes Yes Yes
    Lying down at noon to rest when circumstances permit. Yes Yes Yes Yes
    Sitting while talking with someone. Yes Yes Yes Yes
    Sitting quietly after a meal (without alcohol). Yes Yes Yes Yes
    In the car, while waiting in traffic for a few minutes. Yes Yes Yes Yes
    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?

    Have you had asthma? (select one of the following)

    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?

    Explain:

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

    Explain:

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

    Explain:

    COUGH AND SHORTNESS OF BREATH:

    Do you suffer from a cough?

    Do you normally cough with phlegm?

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

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

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

    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"


    GASTRO OESOPHAGEAL REFLUX / INDIGESTION

    Do you have a history of heartburn or indigestion?
    Describe

    If yes, how often do you have reflux during the day?

    Do you suffer from heart burn / indigestion during the night? How often?

    What aggravates or causes your reflux? Describe

    Do you have difficulty swallowing?
    Describe:

    Does food ever get stuck?
    Describe:

    Does food or fluid cause stomach reflux?
    Describe:

    Does reflux make you vomit?
    Describe:

    Do you suffer from recurring sore throats?
    Describe:

    Do you suffer from a hoarse voice?
    Describe:

    Do you cough at night on a regular basis?
    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: