First Name:       

Last name:        

Phone nbr:       

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Email:                

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Email:                

Address:          

City:                   

State:                 

Postal code:     

Country:            

Friend or Doctor who referred you to our surgery program:

Name referral: 

Date of Birth:  Month:     Day:     Year:     

Sex:          Female Male

Married:  Yes        No           Number of children:

Height:       Feet ('):   Inches("):          or     Meters: Centimeters:

Current Weight:     Pounds (lbs):       .  or     Kilograms (kg):

BMI:   (To calculate your BMI  go to BMI )

Your timeframe for Surgery?  1 - 2 months 3 - 6 Months 6 - 12 Months

Is weight loss surgery covered by your  health insurance?

Yes No Don't know
 

Family History of Obesity:   Parent Yes No    Children: Yes No

Cardiovascular:

High Blood Pressure
Heart Attack
Stroke
Heart Failure
Chest Pain When Walking/exercising
Varicose Veins
Phlebitis-Pulmonary Embolus

Respiratory:

Chronic Cough/Emphysema
Asthma
 Sleep Apnea: NoneMild Severe

Gastrointestinal:

Hiatus Hernia and/or Heartburn
Stomach Ulcers
Gallstones
Chronic Constipation
Blood with Bowel Movement

Endocrine:

Thyroid
Diabetes I    Diabetes II
Diabetes Therapy Diet  Pills  Insulin
High Cholesterol/Triglycerides
Other Endocrine

Musculo-Skeletal:

Any other diseases:

Neurological
Urinary
 Describe other diseases:

Surgeries  (non-bariatric)

Mark to indicate Surgery within last two years
List all non-bariatric surgeries ever below:
 List surgeries:

Any Bariatric Surgeries:

Mark to indicate Bariatric Surgery within last two years
List all Bariatric Surgeries ever below:
List surgeries:

Drugs:

Diet pills
Substance Abuse
Smoking
 Alcohol drinks/day:

Medications:

Prescribed medication:
Please list:

Self-Administered (e.g. Aspirin, diet pills etc.)
Please list:

Enter any other relevant medical condition not covered above or add any  remarks to any condition marked above.

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Please enter any other relevant remarks and reasons why you like to explore weight loss surgery in Brazil:

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