Bariatric Questionnaire

Personal InformationWe do not share this information. Any other disclaimer.

Do you have children? Yes No

Weight History

Would you please indicate your weight at the following times? Please tell whether you consider your weight was below average, average, above average, or very heavy in relevant boxes.

WEIGHT LOSS HISTORY

PLEASE CHECK THE DIET PROGRAMS THAT APPLY TO YOU and indicate its DURATION

Fad diets Yes No

Were there any particular events that lead to significant weight gain: Yes No

Details of any other weight loss measures (including surgical)

Family Medical History

Do you have a family history of any of the following and if so, please indicate:

Allergies and Substance Intake

Surgical History

Please give details of any past operations (especially bariatric)

Any previous surgery Yes No

Have you had any infectious diseases before? HIV Streptococcus Influenza Flu Other

Personal medical History

Have you suffered from any of the following?

Medication

Have you ever taken medications for any of the following?

Medications taken in the last 12 months (include any dietary supplements, cremes, eye drops, etc.)

Please indicate if you take any of the following medications, as taking them before surgery may put your life at risk and cause suspension of the procedure.Clopidogrel (Plavix)Enoxaparin (Clexane) Warfarin (Coumadin) Acetylsalicylic Acid (Aspirin)

Breathing History

Any changes in medication (with or without prescription) must be informed immediately in written form to Medical Tourism Corporation.

Does being at work ever make your chest tight or wheezy? Yes No

Have you ever had asthma? Never Currently In the past Don't know

Gastro Esophageal Reflex/Indigestion

Please list any related treatments

Med Tourism Co LLC (www.medicaltourismco.com) connects patients to one of the best hospitals in the world. Med Tourism Co LLC does not provide advice on medical treatments nor makes claims or guarantees on the outcome of any medical treatment or surgery. Before making any medical related decision you must thoroughly discuss & seek advice from a qualified medical professional.

I have read the above statement, Terms & Conditions & Health Privacy & Confidentiality Statement on the Medical Tourism Corporation Website.

*W = Weight	Below Average	Average Weight	Above Average	Very Heavy
Birth *W
*W at beginning of high school (10-12 yrs)
*W at end of high school (15-18 years)
*W at time of commencing work (21 years)
*W at time of marriage (if applicable)

	Parent	Sibling /Child	Other Relatives	No Family History	Don't Know
*Diabetes
*Heart Disease
*Hypertension
*Gout
*Gallstones
*Obesity
*Snoring
*Asthma
*Allergies
*Hay fever
*Dermatitis /Eczema
*High Cholesterol
*Osteoporosis
*Hip fractures