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Bariatric Questonnaire

Personal Information

Gender

Emergency Contact

Medical

Do you have a passport?:

Social Profile

Your Marital status:
Do you have children?

Weight History

*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)
Since when have you been overweight?

WEIGHT LOSS HISTORY

Weight Watchers
Jenny Craig/Nutrisystem/Gloria Marshall etc
Appetite suppressants
Any other drug treatment
Fad diets
Were there any particular events that lead to significant weight gain:
Details of any other weight loss measures (including surgical)

Family Medical History

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

Allergies and Substance Intake

Recreational drug use
Do you smoke?
Any allergies
Do you drink alcohol?

Surgical History

Any previous surgery
Have you had any infectious diseases before?

Personal medical History

Diabetes
Diabetes while pregnant
Asthma
Respiratory/Breathing problems
Arthritis or joint pain
Kidney or urinary disorder
Neurological disorder
Psychological/nervous disorder
Gallstones
Thrombosis or clotting disorder
Gastric or duodenal ulcer
Hepatitis or liver disease
High blood pressure
Heart disease
High cholesterol
Anemia or bleeding disorder
Varicose veins or leg swelling
Eczema or skin condition
Hayfever or Rhinitis
Back pain

Sleep Apnea

Do you have sleep apnea?
Do you use CPAP machine??

Medication

Migraine
Weight loss assistance:
Epilepsy
Asthma or breathing:
Psychiatric disorder
Hormones, e.g., the pill:
HRT
Cortisone:
Blood thinners
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.

Breathing History

Does being at work ever make your chest tight or wheezy?
Have you ever had asthma?

Gastro Esophageal Reflex/Indigestion

History of heartburn, acid reflux or indigestion
Please list any related treatments

OB/GYN

Pregnancies, births, abortions (if any)
How did you hear about us?

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.





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