Medical Tourism Corporation
Med Tourism Co. LLC, Medical Tourism, Plano, TX
1-800-661-2126
1-214-717-4775
PROCEDURES
Dental

Bariatric Questionnaire

PERSONAL DETAILS

Desired Destination
Desired Medical Procedure
Name of the Surgeon:
*First Name:
*Last Name:
*Address:
*Postcode:
*Telephone No: (Home)
*Your E-Mail Address
Telephone No: (Business)
Mobile No:
*Date Of Birth:
*Age:
*Occupation:
*Language Spoken: (Example: 'English')
*Proposed Surgical Date
*Do you have a passport? YesNo

CONTACT PERSONS:

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

1. NEXT OF KIN

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

PRIMARY HEALTHCARE PROVIDER

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

SOCIAL PROFILE

FAMILY STRUCTURE:

*Marital Status: MarriedSingle
If married or previously married, what is your current status? DivorcedPartner/Relationship
Children/Ages:

WEIGHT HISTORY

Please indicate your weight at the following times. Please indicate whether you consider your weight was below average, average, above average or very heavy in the relevant boxes.
  Below Average Average Weight Above Average Very Heavy
*Birth Weight
*Weight at beginning of high school (10-12 yrs)
*Weight at end of high school (15-18 years)
*Weight at time of commencing work (21 years)
Weight at time of marriage (if applicable)
*Current Weight
*Height
*BMI
*Current Body Shape  Apple Shape  Pear Shape  Other  Don't Know
if other, please describe:
*Waist Circumference

WEIGHT LOSS HISTORY

 

PAST ATTEMPTS

 
*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
If yes, please explain:
 

FAMILY MEDICAL HISTORY

 
Do you have a family history of any of the following and if so, please indicate:
  PARENT SIBLING/CHILD OTHER RELATIVES
(cousins, aunts, grandparents etc)
NO FAMILY HISTORY DON�T KNOW
*Diabetes
*Heart Disease
*Hypertension
*Gout
*Gallstones
*Obesity
*Snoring / sleep apnea
*Asthma
*Allergies
*Hay fever
*Dermatitis / Eczema
*High Cholesterol
*Osteoporosis
*Hip fractures

*ALLERGIES?

 YesNo
(including foods, medications, dressings)
If yes, please give details:

 

ALCOHOL:

 
*Do you drink alcohol? NeverRarelyRegularly
How many standard glasses do you drink per day?
How many days do you drink per week?
What do you drink? BeerWineSpirits
 

SMOKING:

 
*Do you smoke?  YesNoNever
If yes: how many per day?
Have you smoked in the past?  YesNo
If so, how many per day?
If so, for how many years?
If so, when did you stop smoking?
 

SURGICAL HISTORY - Please give details of any past operations:

 

PERSONAL MEDICAL HISTORY

 
Have you ever suffered with any of the following health problems?
*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 Yes No
if yes, Details?
*Psychological/nervous disorder Yes No
if yes, Details?
*Gallstones Yes No
if yes, Details?
*Reflux or heartburn 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?
*Thrombosis or clotting 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?
Please give details of any major illnesses/problems

SLEEP HISTORY

 
*How many hours sleep do you get a night?
*Is there any thing else that keeps you awake at night? Yes No
if yes, Details?

SYMPTOMS OF SLEEP APNEA

*1. How often do you Snore? Never Rarely Occasionally Frequently Always
*2. Do you wake during the night with a choking feeling? Never Rarely Occasionally Frequently Always
*3. How often would you sleep more than 8 hours in total in a 24 hour period? Never Rarely Occasionally Frequently Always
*4. Do you feel sleepy during the day? Never Rarely Occasionally Frequently Always
*5. Has anyone noticed that you momentarily stop breathing during your sleep? Never Rarely Occasionally Frequently Always
*6. How often do you doze off or fall asleep while driving? Never Rarely Occasionally Frequently Always

EMPLOYMENT

 
*Are you currently employed? Yes No
Current Employment:
Are you full-time, part-time or casual? Full time Part Time Casual
If you are unemployed, what is the reason?
*Are you actively looking for work? Yes No
*Has your weight made it difficult to find employment? Yes No
If employed, please state what level of activity your job involves: Little (sedentary job)Moderately activeVery active (Labouring, etc.)

MEDICATIONS

 
Please indicate whether you are now or have previously taken any of the following medications.
If yes, please state the name of the medication and how long you have been or were taking it.
*Medication for psychiatric disorder Yes No
if yes, Details?
*Migraine medication Yes No
if yes, Details?
*Medications to assist weight loss Yes No
if yes, Details?
*Drugs for epilepsy Yes No
if yes, Details?
*Drugs for 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?
*Please list in detail all medications that you have used in the last 12 months.
Please include any dietary supplements, cremes, eye drops, etc.

BREATHING HISTORY

 
*Does being at work ever make your chest tight or wheezy? Yes No
if yes, Details?

ASTHMA

 
*Have you ever had asthma? (tick one of the following) NeverCurrentIn the pastDon�t know

GASTRO ESOPHAGEAL REFLUX / INDIGESTION

*Do you have a history of heartburn or indigestion? Yes No
Details
If yes, how often do you have reflux during the day? Many times a dayeverydaymost daysmost weeksoccasionally
*Do you suffer heart burn / indigestion during the night? Yes No
If so how often Many times a dayeverydaymost daysmost weeksoccasionally
What aggravates or causes your reflux?
*Do you have difficulty swallowing? Yes No
if yes, Details?
*Does food ever get stuck? Yes No
if yes, Details?
*Does food or fluid reflux into the mouth? Yes No
if yes, Details?
*Do you vomit with reflux? Yes No
if yes, Details?
*Do you suffer from recurrent sore throats? Yes No
if yes, Details?
*Do you suffer from a hoarse voice? Yes No
if yes, Details?
*Do you suffer from a regular cough at night? Yes No
if yes, Details?
Please list any treatments you may use for reflux / heartburn or indigestion

OB/ GYN:

 
Please, specify pregnancies, births, abortions:

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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.

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