Bariatric Questionnaire    

The information you provide will help us to plan your treatment, please carefully fill out and sign the last page.

PERSONAL DETAILS

Desired Destination:
Desired Medical Procedure:
First Name:*
Last Name:*
Contact No:*
Secondary Contact No:
Address & Country:*
Zip/ Postal Code:*
Your E-Mail Address:*
Date of Birth:*
Age:
Sex(M/F):
Occupation:*
Language Spoken:*
Proposed Surgical Date:
Do you have a passport?*
Yes   No

PRIMARY HEALTHCARE PROVIDER

Name of the provider:
How long he/she has been treating you?
Telephone:
Any other physician/s?
Conditions Treated:
Address of the provider:

EMERGENCY CONTACT PERSON

This information is often vital to us if we need to contact you urgently. Occasionally people move or have new phone numbers, and they do not let us know.

Name:*
Relationship:*
*Address:
Telephone No (Home):*
Telephone No (Business):

SOCIAL PROFILE

*Marital Status:

Married   Single  

Divorced   Widowed  

Other (please specify)  
Do you have children?
Yes   No
If yes, please specify their age and number of kids (if applicable)

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.
 *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)
Current Weight (lbs):*
Current Height (cm):*
Overweight since when?
Current Body Shape:
 Apple   Pear  Other 

WEIGHT LOSS HISTORY


PLEASE CHECK THE DIET PROGRAMS THAT APPLY TO YOU and indicate its DURATION
Weight Watchers
Yes   No
if yes, Duration?
*Jenny Craig/Nutrisystem/Gloria Marshall etc
Yes   No
If yes, Duration?
*Fad diets
Yes   No
if yes, Duration?
*Appetite suppressants
Yes   No
if yes, Duration?
*Any other drug treatment
Yes   No
If yes, Duration?
*Details of any other weight loss measures (including surgical):
*Were there any particular events that lead to significant weight gain:
Yes   No

FAMILY MEDICAL HISTORY

Do you have a family history of any of the following and if so, please indicate:
   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:*
Yes   No
If yes, please give details:
Do you smoke?*
Often   Sometimes   Never
Any allergies:*
Yes   No
If yes, please give details (foods, medications,etc):
Do you drink alcohol?*
Often   Sometimes   Never

SURGICAL HISTORY

Please give details of any past operations (especially bariatric):
Any previous surgery:*
Yes   No
If yes, which surgery?
Have you had any infectious diseases before?

PERSONAL MEDICAL HISTORY

Have you suffered from any of the following?
Diabetes:*
Yes   No
If yes, details?
Diabetes while pregnant:*
Yes   No
If yes, details?
Asthma:*
Yes   No
If yes, details?
Respiratory/Breathing problems:*
Yes   No
If yes, details?
Arthritis or joint pain:*
Yes   No
If yes, details?
Back pain:*
Yes   No
If yes, details?
Kidney or urinary disorder:*
Yes   No
If yes, details?
Neurological/nervous disorders:*
Yes   No
If yes, details?
Psychological/mental disorder:*
Yes   No
If yes, details?
Thrombosis or clotting disorder:*
Yes   No
If yes, details?
Gastric or duodenal ulcer:*
Yes   No
If yes, details?
Hepatitis or liver disease:*
Yes   No
If yes, details?
High blood pressure:*
Yes   No
If yes, details?
Heart disease:*
Yes   No
If yes, details?
High cholesterol:*
Yes   No
If yes, details?
Anemia or bleeding disorder:*
Yes   No
If yes, details?
Varicose veins or leg swelling:*
Yes   No
If yes, details?
Eczema or skin condition:*
Yes   No
If yes, details?
Hayfever or Rhinitis:*
Yes   No
If yes, details?
Gallstones:*
Yes   No
If yes, details?
Any other:
List all medications you currently take including dosage:

SLEEP APNEA

Do you have sleep apnea?*
Yes   No
Do you use a CPAP machine?*
Yes   No

EMPLOYMENT

Are you currently employed?
Yes   No
Current Employment:
Please state what level of activity your job involves:
Little (sedentary job)  
Moderately active  
Very active (labouring, etc.)

MEDICATIONS

Have you ever taken medications for any of the following medical issues?
Psychiatric disorder:*
Yes   No
If yes, details?
Migraine:*
Yes   No
If yes, details?
Weight loss assistance:*
Yes   No
If yes, details?
Epilepsy:*
Yes   No
If yes, details?
Asthma or breathing:*
Yes   No
If yes, details?
Hormones, e.g., the pill:*
Yes   No
If yes, details?
HRT:*
Yes   No
If yes, details?
Cortisone:*
Yes   No
If yes, details?
Blood thinners:*
Yes   No
If yes, details?
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)  

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

BREATHING HISTORY

*Does being at work ever make your chest tight or wheezy?
Yes   No
if yes, Details?
*Have you ever had asthma?
Never
Currently
In the past
Don't know

GASTRO ESOPHAGEAL REFLUX/ INDIGESTION

History of heartburn, acid reflux or indigestion:*
Yes   No
Please list any related treatments:

OB/ GYN:

Pregnancies, births, abortions (if any):

PATIENT COVID-19 FORM

Have you been diagnosed with COVID - 19?
Yes   No
If you answered yes, how long ago were you diagnosed? (specify month and year)
Full Name:
Date of Birth:
Age:
Sex(M/F):
Surgeon in charge:
 PRESENTED IN THE PAST 15 DAYS   YES   NO 
 Fever over 38°C
 Dry cough
 Headache
 Difficulty breathing
If you answered yes to any of the questions above, please explain when and how:
 HAVE YOU FELT ANY OF THE FOLLOWING IN THE PAST 15 DAYS? 
    YES   NO 
 Muscle pain
 Joint pain
 Sore throat / burning throat
 Conjunctivitis
 Chest pain
 Nasal congestion
 Tiredness
    YES   NO 
 Chills
 Nausea / Throw up
 Phlegm / Expectoration
 Diarrhea
 Lack of smell
 Lack of taste
If you answered yes to any of the questions above, please explain when and how:
Have you used any of the following safety measures:
Respiratory mask:
  YES     NO
Gloves:
  YES     NO
Hand wash/sanitizer:
  YES     NO
I do not use security measures:
  YES     NO
Have you had close contact with COVID-19 patient, in last 14 days?
  YES     NO
I understand that full disclosure is necessary for my medical safety. I have filled out this medical history to the best of my knowledge, and I have answered these questions with complete honesty to ensure my health and safety.


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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.