First Name
Last Name
Age
Date of birt
Email
Phone
Martial Status
Street Address
City
State/Province
Country
Surgery Request
Select an option
Gastrict Sleve
Gastric Bypass
Duodenal Switch
Date of Surgery
Have you had any previous surgery?
If ‘yes ‘ please list surgeries
Significant hospitalization
Rheumatic fever or heart disease
If you have answered yes to any of the above questions, please list the details below if appropriate
Medications currently taken
Colitis or Crohn’s Disease
Father
Mother
Please enter any other important family history not listed above:
Drinking alcohol
Never
Rarely
Moderately
I don't know
How often?
Smoking
Never
Previously smoked
Presently smoking
How often?
Cups per day?
Are you exposed to fumes, dust or solvents?
What is your job/ occupation?
Drugs recently taken – within the past six months
If you selected another, tell us which one it is
If you selected another, tell us which one it is
If you selected another, tell us which one it is
If you selected another, tell us which one it is
If you selected another, tell us which one it is
If you selected another, tell us which one it is
Other drugs or medication
Height
Weight
BMI
Good health in general
Selecc
Yes
No
I don't know
Fevers
Selecc
Yes
No
I don't know
Change in appetite
Selecc
Yes
No
I don't know
Change in appetite
Selecc
Yes
No
I don't know
Frequent infection or boils
Selecc
Yes
No
I don't know
Pain with swallowing
Selecc
Yes
No
I don't know
Trouble swallowing (eg. food sticks in the throat)
Selecc
Yes
No
I don't know
Regurgitation of food
Selecc
Yes
No
I don't know
Belching
Selecc
Yes
No
I don't know
Nausea
Selecc
Yes
No
I don't know
Peptic Ulcer Disease (stomach or duodenum)
Selecc
Yes
No
I don't know
Surgery to the esophagus
Selecc
Yes
No
I don't know
Surgery to the stomach
Selecc
Yes
No
I don't know
Surgery to the large intestines (colon)
Selecc
Yes
No
I don't know
Bloating
Selecc
Yes
No
I don't know
Abdominal pain
Selecc
Yes
No
I don't know
Pain after meals
Selecc
Yes
No
I don't know
Food intolerance
Selecc
Yes
No
I don't know
Gall bladder disease (e.g. surgery or gallstone)
Selecc
Yes
No
I don't know
Liver disease
Selecc
Yes
No
I don't know
Jaundice
Selecc
Yes
No
I don't know
Hepatitis
Selecc
Yes
No
I don't know
Blood Transfusion
Selecc
Yes
No
I don't know
Pancreas Disease
Selecc
Yes
No
I don't know
Constipation
Selecc
Yes
No
I don't know
Diarrhea
Selecc
Yes
No
I don't know
Laxative use
Selecc
Yes
No
I don't know
Black colored bowel movements
Selecc
Yes
No
I don't know
Colitis
Selecc
Yes
No
I don't know
Diverticulosis
Selecc
Yes
No
I don't know
Polyps
Selecc
Yes
No
I don't know
Recent change in bowel habits
Selecc
Yes
No
I don't know
Painful bowel movements
Selecc
Yes
No
I don't know
Blood in the stool
Selecc
Yes
No
I don't know
Mucus in the stool
Selecc
Yes
No
I don't know
Pus in the stool
Selecc
Yes
No
I don't know
Fistula
Selecc
Yes
No
I don't know
Hemorrhoids
Selecc
Yes
No
I don't know
Anal fissures
Selecc
Yes
No
I don't know
Anal pain or cramps
Selecc
Yes
No
I don't know
Anal itching
Selecc
Yes
No
I don't know
Bowel movements in the late night
Selecc
Yes
No
I don't know
Irregular bowel movements (inability to control timing)
Selecc
Yes
No
I don't know
Skin Disease
Selecc
Yes
No
I don't know
Jaundice
Selecc
Yes
No
I don't know
Hives
Selecc
Yes
No
I don't know
Rash
Selecc
Yes
No
I don't know
Eczema
Selecc
Yes
No
I don't know
Abnormal Pigmentation
Selecc
Yes
No
I don't know
Frequent infection or boils
Selecc
Yes
No
I don't know
Spitting up blood
Selecc
Yes
No
I don't know
Chronic or frequent cough
Selecc
Yes
No
I don't know
Asthma
Selecc
Yes
No
I don't know
Wheezing
Selecc
Yes
No
I don't know
Difficulty breathing
Selecc
Yes
No
I don't know
Any trouble with lungs
Selecc
Yes
No
I don't know
Pleurisy
Selecc
Yes
No
I don't know
Pneumonia
Selecc
Yes
No
I don't know
System review Gynecological
Selecc
Yes
No
I don't know
Gynecological
Selecc
Yes
Not Applicable
Periods
Age started / year
Age Duration / Days/ year
Frequency (days)
Pregnancies
Miscarriages
Date of first day of last period
Endometriosis
Selecc
Yes
No
I don't know
Stiffness
Selecc
Yes
No
I don't know
Thyroid trouble
Selecc
Yes
No
I don't know
Do you wear contacts?
Selecc
Yes
No
I don't know
Eye disease or injury
Selecc
Yes
No
I don't know
Double vision
Selecc
Yes
No
I don't know
Headaches
Selecc
Yes
No
I don't know
Glaucoma
Selecc
Yes
No
I don't know
Itchy eyes or nose
Selecc
Yes
No
I don't know
Nosebleeds
Selecc
Yes
No
I don't know
Chronic sinus trouble
Selecc
Yes
No
I don't know
Impaired hearing
Selecc
Yes
No
I don't know
Dizziness
Selecc
Yes
No
I don't know
Transient episodes of unconsciousness
Selecc
Yes
No
I don't know
Chest pain or angina pectoris
Selecc
Yes
No
I don't know
Shortness of breath with walking
Selecc
Yes
No
I don't know
Heart trouble or heart attacks
Selecc
Yes
No
I don't know
High blood pressure
Selecc
Yes
No
I don't know
Swelling of hands
Selecc
Yes
No
I don't know
Swelling of feet
Selecc
Yes
No
I don't know
Swelling of ankles
Selecc
Yes
No
I don't know
Heart murmur
Selecc
Yes
No
I don't know
Valvular heart disorder
Selecc
Yes
No
I don't know
Frequent urination
Selecc
Yes
No
I don't know
Loss of urine
Selecc
Yes
No
I don't know
Night time urination
Selecc
Yes
No
I don't know
Burning or painful urination
Selecc
Yes
No
I don't know
Blood in the urine
Selecc
Yes
No
I don't know
Kidney trouble
Selecc
Yes
No
I don't know
Kidney stones
Selecc
Yes
No
I don't know
Varicose veins
Selecc
Yes
No
I don't know
Weakness of joints
Selecc
Yes
No
I don't know
Any difficulty walking
Selecc
Yes
No
I don't know
Claudication
Selecc
Yes
No
I don't know
Arthritis
Selecc
Yes
No
I don't know
Back pain
Selecc
Yes
No
I don't know
Ever had psychiatric care?
Selecc
Yes
No
I don't know
Ever advised to see a psychiatrist?
Selecc
Yes
No
I don't know
Fainting spells
Selecc
Yes
No
I don't know
Convulsions
Selecc
Yes
No
I don't know
Paralysis
Selecc
Yes
No
I don't know
Are you slow to heal after cuts?
Selecc
Yes
No
I don't know
Blood disease
Selecc
Yes
No
I don't know
Anemia
Selecc
Yes
No
I don't know
Iron deficiency
Selecc
Yes
No
I don't know
Iron overload
Selecc
Yes
No
I don't know
Phlebitis
Selecc
Yes
No
I don't know
Abnormal brusing
Selecc
Yes
No
I don't know
Abnormal bleeding
Selecc
Yes
No
I don't know
Thalassemia
Selecc
Yes
No
I don't know
Thyroid disease
Selecc
Yes
No
I don't know
Hormone therapy
Selecc
Yes
No
I don't know
Change in hat or glove size
Selecc
Yes
No
I don't know
Any change in hair growth
Selecc
Yes
No
I don't know
High cholesterol
Selecc
Yes
No
I don't know
High triglyceride
Selecc
Yes
No
I don't know
Hot intolerance
Selecc
Yes
No
I don't know
Cold intolerance
Selecc
Yes
No
I don't know
History of excessive bleeding (after tooth extraction or surgery)
Selecc
Yes
No
I don't know
Diabetes
Selecc
Yes
No
I don't know
Have you ever been in any kind of counseling or therapy? Please describe:
Are you or have you ever been under a psychiatrist’s care? If yes, what was your diagnosis?
Have you ever participated in a support group? Please describe:
Are you or have you ever taken psychiatric medications? Please describe and for what purpose:
How long has excess weight been an issue in your life?
What methods have you tried to lose weight?
What do you hope to obtain from this surgery?
What are some of the changes you want to make in your lifestyle upon having this surgery?
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