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Patient Medical Questionnaire
Desired Medical Procedure
Preferred Surgery Date
Personal information
First Name
Last Name
Gender
Date Of Birth
Age
Do you have a valid passport?
Occupation
Language Spoken
Contact information
Email
Telephone
Home Address
Country
State
City
Zip Code
Medical History
Why is the Treatment required?
Was the Treatment recommended by a doctor?
Have you had any imaging/studies already performed?
Have you had any blood tests already performed in the past 30 days?
YesNo
Current Weight
Height:
BMI
Marital Status
What is your typical job activity level?
Have you had any previous surgeries?
Surgery
Date
Reason
Do you have any anesthesia problems?
Explain
Do you have any allergies? (Please list all)
Explain
Have you had any pregnancies?
Explain
Do you drink alcohol? (Frequency)
Frequency:
Do you smoke?(Frequency)
Frequency:
Do you have diabetes?
Explain
Do you have a Heart Disorder?
Explain
Do you suffer from High Blood Pressure?
Explain
Do you have High Cholesterol?
Explain
Do you have any Gout problems?
Explain
Do you have a Kidney or Urinary Disorder?
Explain
Do you suffer from Gallstones?
Explain
Do you suffer from Sleep Apnea?
Explain
Do you suffer from Asthma?
Do you suffer from Dermatitis Eczema?
Explain
Do you have any orthopedic problems?
Explain
Do you have Breathing/Respiratory problems?
Explain
Do you have a Neurological or Psychological Nervous Disorder?
Explain
Do you suffer from Reflux, Heartburn, and/or Gastritis?
Explain
Do you have ulcers?
Explain
Do you have Hepatitis or Liver Disease?
Explain
Do you have Anemia or a Bleeding Disorder?
Explain
Do you suffer from Varicose Veins or Leg Swelling?
Explain
Do you suffer from epilepsy?
Explain
Do you suffer from Rhinitis?
Explain
Do you have difficulty swallowing or recurring sore throat?
Explain
Do you suffer from a hoarse voice or regular cough at night?
Please answer the following questions if inquiring about Weight-Loss Surgery
Did you have Diabetes while pregnant?(*)
Explain:
Have you done any special diets to try to lose weight?(*)
Explain:
Are you on any special diet (Vegan, Vegetarian)?(*)
Explain:
Have you taken Appetite Suppressant?(*)
Explain:
Any other weight-loss drug treatment?(*)
Explain:
Did other events lead to weight gain?(*)
Explain:
Illness History
Have you had any illnesses in the past 5 years? (Please list all)
Illness
Date
Treatment
Outcome
Medication History
Have you taken any medications in the past 12 months? (Please list all)
Name of medications
How often doyou take it?
When did you starttaking it?
Reason