Name (required): Email (required): Phone (required) Gender: MaleFemale Occupation: Date of Birth:
Weight: Height: BMI:
Which Procedure are you interested in? Gastric SleeveSingle Incision Gastric SleeveGastric BypassMini Gastric BypassIntragastric BalloonDuodenal SwitchSADI-SRevision (Lap Band to Gastric SleeveRevision (Lap Band to Gastric Bypass)Revision (Lap Band to Mini Gastric Bypass)Revision (Gastric Sleeve to Gastric Bypass)Revision (Gastric Sleeve to Duodenal Switch)Revision Gastric Sleeve to Mini Gastric Bypass)Revision (Gastric Bypass to Gastric Bypass) Procedure Date:
Have you ever been diagnosed with Hepatitis?: NoYes Have you ever been diagnosed with HIV?: NoYes Do you refuse blood transfusions?: NoYes Have you ever been diagnosed with Hiatal Hernia?: YesNo Do you have any allergies?: NoYes
What type of Allergies?
Do you have Type I Diabetes: NoYes Do you have Type II Diabetes: NoYes Have you been diagnosed with pregestational diabetes? NoYes
Do you suffer from any Heart Disease? NoYes
Please Explain:
Do you have Asthma? NoYes
Do you suffer from High Blood Pressure? NoYes
Do you have any kidney or urinary disorder? NoYes
Do you suffer from any neurological condition? NoYes
Have you been diagnosed with Gallstones? NoYes
Have you been diagnosed from any nervous or psychological disorder? NoYes
Have you had any gastric or duodenal ulcer? NoYes
Have you had any liver disorder? NoYes
Do you currently have anemia or any Blood imbalance? NoYes
Do you suffer from heartburn or reflux? NoYes
Was your gallbladder ever removed? NoYes
Are you receiving kidney dialysis treatments? NoYes
Do you have any additional medical condition to report to the surgeon? NoYes
Disease: Diagnosed Date: Treatment: Outcome:
Do you drink alcoholic beverages?: NoYes
How often:
Do you Smoke? NoYes
Do you use any recreational drugs? NoYes
List your current medications, reason and dosage: Do you take any blood thinner? NoYes
Which and dosage:
Do you have previous surgeries? NoYes
Procedure: Procedure Date: Reason: Procedure Type: OpenLaparoscopic
