Clinical History

Medical Questionnaire

Name *

Email *

Phone Number *

Date of Birth *

Address *

Emergency Contact *

Emergency Contact Phone Number *

Height *

Weight *

What surgery are you interested in? *

Gastric Bypass Gastric Sleeve Revision Surgery Mini Gastric Bypass

Have you had any weight loss surgery before? *

Yes No

Which surgery did you have? *

Gastric Bypass Gastric Sleeve Mini Gastric Bypass Other

Do you have sleep apnea? *

Yes No

Do you use a CPAP machine as treatment for sleep apnea? *

Yes No

Do you have any of the following metabolic conditions?

Diabetes Hypothyroidism Hyperthyroidism Arterial hypertension Dyslipidemias (cholesterol and triglycerides) None Other

Have you had any of the following cardiac conditions?

Heart attacks Heart failure Stenosis of cardiac valves (aortic and tricuspid) None Other

Have you had any of the following digestive conditions?

Gastroesophageal reflux Hiatal hernia Helicobacter pylori infection Lactose intolerance Diverticulitis Irritable bowel syndrome Constipation None Other

Do you have a pre-existent pulmonary condition? *

Asthma Chronic Obstructive Pulmonary Disease (COPD) None Other

Do you have any other type of disease such as epilepsy, anemia, rheumatoid arthritis, lupus, among others? *

Yes No

Do you take any medications? If so, please specify: *

Do you have any allergies? If so, please specify: *

Previous Surgeries: *

Upload your latest lab results:

Accepted formats: PDF, JPG, PNG, DOC, DOCX (Max 10MB)

Do you smoke? *

Yes No

Do you consume any drugs? *

Yes No

Do you have any additional questions or comments?

Decídete a cambiar tu vida y permítenos ayudarte, ponte en contacto con nosotros para resolver cualquier duda que tengas.

Cirugía Bariátrica Tijuana

El Dr. Jorge Maytorena es un cirujano bariatra con más de 15 años de experiencia, ha realizado más de 10,000 procedimientos quirúrgicos entre manga gástrica, bypass gástrico y cirugías de revisión.

Clinica de Control de Peso

USA +1 (619) 759 1331
admissionsmaytorena@gmail.com

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