Date of Birth:
Height:
Weight:
Surgery Interest? —Please choose an option—Gastric BypassGastric SleeveMini Gastric BypassSADIRevisional Surgery
Any previous Weight Loss Surgery? —Please choose an option—YesNo
Any previous Surgery: —Please choose an option—Hiatal HerniaGallbladerC-SectionPlastic SurgeryOthersNone
Do you have sleep apnea? —Please choose an option—YesNo
Do you have CPAP? —Please choose an option—YesNo
Do you have metabolic condition? —Please choose an option—DiabetesHypertensionDyslipidemiaHypothyroidismHyperthyroidismNone
Do you have heart condition? —Please choose an option—Clotting disorderCardiac arrhythmiaHeart attackPeripherial artery diseaseHeart valve diseaseCongestive heart dailureCongenital heart diseaseNoneOther
Do you have digestive condition? —Please choose an option—Acid refluxGastric ulcerGallstonesUlcerative colitisCrohn'sDiverticulitisNone
Do you smoke? —Please choose an option—YesNo
How many?
Do you do drugs? —Please choose an option—YesNo
What kind and how often?
