Application form for intragastric balloon implantation

APPLICATION FORM FOR INTRAGASTRIC BALLOON IMPLANTATION

Please give us your general information
First name*
Last name*
Age*
Occupation*
Date of birth*
Gender*
E-mail*
Phone*
Please fill in your measures
Height*
Weight*
BMI*
What the highest weight was in your life (kg)?*
Other information
How long have you been overweight?*
What have you done to try to lose weight?*
Are you a snacker?*
Are you a volume eater?*
Do you eat a lot of sweets?*
Do you frequently eat fast food and/or drink carbonated beverages?*
Do you drink alcohol? If yes, please tell us how often and how much:*
Do you smoke? If yes, please tell us how often and how much:*
Do you have any other addictions?*
Do you use any substances?*
Please tell us about your personal health history
Diabetes (Type)*
Cancer (Type)*
Overweight*
Obesity*
Heart diseases (Type)*
Blood pressure*
Gastric symptoms*
Do you experience shortness of breath with physical activity?*
Do you have or had asthma?*
Do you have any allergies? If yes, for what?*
Have you been diagnosed with fatty liver, cirrhosis, hepatitis or any other liver disease?*
Do you have indigestion or heart burn?*
Have you been diagnosed HIV positive, lupus infection?*
Please list any current medications you are taking
*
Name of medication / How often taken When started / Reason
Name any previous medications*
Please list any major illnesses you have had
*
Illness / Date Treatment / Outcome
Please list any additional information you believe would assist in your health planning
Additional information*
Preferred date of the procedure*
I declare that I have truthfully completed this form any have not made any purposeful omissions:*
- Yes
- No
I confirm that I understand confidentiality information*
- Yes
- No
Date of filling out the form*

Weight:	kg
Height:	cm

Name of medication / How often taken	When started / Reason

Illness / Date	Treatment / Outcome

Application form for intragastric balloon implantation

APPLICATION FORM FOR INTRAGASTRIC BALLOON IMPLANTATION

Please give us your general information

Please fill in your measures

Other information

Please tell us about your personal health history

Please list any current medications you are taking

Please list any major illnesses you have had

Please list any additional information you believe would assist in your health planning