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Type of Surgery
ORBERA - Intragastric BalloonSPATZ - Intragastric BalloonGastric bandGastric sleeveGastric Bypass - 1 AnastomosisGastric Bypass - Roux Y
Details of any other types of weight loss (including surgical)
Mention all important illnesses your close relatives suffer from (Parents, Brothers, Uncles, Grandparents, Children).
If any, please give detail
ALLERGIES (including food, medications, etc.): YesNo
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.
Usually, when do you drink? Social eventsPartiesWith mealsBefore / after eatingWeekends
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?
Have you ever suffered from any of the following health problems:
Please give details of any major illnesses/problems
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:
Please list all medications that you have taken in the last 12 months.
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) YesNoIf 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? YesNoExplain:
In the past 12 months, have you taken prednisolone do to asthma or breathing problems. YesNoExplain:
In the last 12 months, have you missed work or school do to asthma or respiratory problems. YesNoExplain:
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
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
Do you have a history of heartburn or indigestion? YesNoDescribe
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? YesNoDescribe:
Does food ever get stuck? YesNoDescribe:
Does food or fluid cause stomach reflux? YesNoDescribe:
Does reflux make you vomit? YesNoDescribe:
Do you suffer from recurring sore throats? YesNoDescribe:
Do you suffer from a hoarse voice? YesNoDescribe:
Do you cough at night on a regular basis? YesNoDescribe:
Please list any treatments you may use for reflux / heartburn or indigestion
Please give full detail of any surgeries that you had in the past: