Bariatric Health Questionnaire

Name: ^*

Email ^*

Address

City

State

Country

Phone Number: ^*

Mobile Phone

Date of Birth

Age

Gender

Height

Weight

BMI

Desired Bariatric Procedure

Procedure Date

Current Illness

Diagnosed Date

Treatment

Outcome

Do you have Type I Diabetes

Yes

Do you have Type II Diabetes

Yes

Have you been diagnosed with pregestational diabetes?

Yes

Do you suffer from any Heart Disease? (If yes, please explain)

Do you have Asthma?

Do you have any breathing or respiratory problems?

Do you suffer from High Blood Pressure?

Do you have any kidney or urinary disorder? (If yes, please explain)

Do you suffer from any neurological condition? (If yes, please explain)

Have you been diagnosed with Gallstones?

Have you been diagnosed from any nervous or psychological disorder?

Have you had any gastric or duodenal ulcer?

Have you ever been diagnosed with Hepatitis or any liver disorder?

Do you currently have anemia or any Blood imbalance?

Do you suffer from heartburn or reflux?

Do you any other medical condition not listed above?

Are you allergic to any medication? (If yes, please explain)

Are you allergic to latex?

Are you allergic to any kind of food? (If yes, please explain)

Do you Drink Alcoholic Beverages?

Yes

Do you Smoke?

Yes

Do you use recreational drugs?

Yes

List your current medications, reason and dosage.

Do you take aspirin, baby aspirin, heparin, coumadin, warfarin, lovenox or any othe blood thinner?

If yes, please explain reason.

Was your gallbladder ever removed?

Yes

Are you receiving kidney dialysis treatments?

Yes

Are you currently wearing a colostomy bag?

Yes

Are you prone to Blood Cloths?

Yes

Have you ever been told that you have Nephrotic Syndrome?

Yes

Have you ever been diagnosed with Deep Vein Thrombosis?

Yes

Do you have Von Willdebrand Disease?

Yes

What is the extent of your Von Willebrand Disease?

What were the previous complications in any surgery you've had related to Von Willebrand Disease?

Do you have bleeding when you brush your teeth due to the Von Willebrand Disease?

Have you ever had a pulmonary embolism?

Yes

Where you given medicine for Pulmonary Embolism?

Yes

List de medicine taken due to Pulmonary Embolism

Do you have primary billiary Cirrhosis?

Yes

Do you currently use a CPAP machine?

Yes

Have you or any family member had an adverse reaction to anesthesia?

Yes

Do you have a previous Weight Loss Surgery?

Yes

Surgery Method?

Laparoscopic

Open

What was your highest weight before your first WLS?

Please describe your previous weight loss

Please list and describe any previous surgery

Please list and describe any previous hospitalizations

Comments or additional information you think it might be useful for the doctors.

Health Questionnaire

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