Application form for bariatric surgery

APPLICATION FORM FOR BARIATRIC SURGERY

BARIATRIC SURGEON ANTANAS MICKEVICIUS MD, PhD

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 (cm)*
Weight (kg)*
BMI*
What the highest weight was in your life (kg)?*
Please tell us about your diet history
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?*
What foods or drinks cause you digestive problems?*
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?*
Please tell us about your personal health history
Diabetes (Type / Medication)*
Cancer (Type)*
Overweight*
Obesity*
Heart disease (Type)*
High blood pressure*
Gastric symptoms (Type)*
Do you experience shortness of breath with physical activity?*
Do you exercise regularly?*
Do you have or had asthma?*
Do you have thyroid problems?*
Do you have any allergies?*
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 for lupus?*
Have you been diagnosed HIV positive?*
Please tell us about your family health history
Diabetes (Family member / Type)*
Cancer (Family member / Type)*
Overweight (Family member)*
Obesity (Family member)*
Heart disease (Family member / Type)*
High blood pressure (Family member)*
Other (Family member / Type)*
Please list any previous surgeries you have had
*
Surgery Reason / date
Please list any current medications you are taking
*
Name of medication / How often taken When use 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
Preferred type of bariatric surgery and date:*
- Gastric Bypass
- Gastric Sleeve
- Gastric Plication
- Revisional Bariatric Surgery
Surgery date*
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*

Surgery	Reason / date

Name of medication / How often taken	When use started / Reason

Illness / Date	Treatment / Outcome

Weight:	kg
Height:	cm

Application form for bariatric surgery

APPLICATION FORM FOR BARIATRIC SURGERY

Please give us your general information

Please fill in your measures

Please tell us about your diet history

Please tell us about your personal health history

Please tell us about your family health history

Please list any previous surgeries you have had

Please list any current medications you are taking

Please list any major illnesses you have had