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: