Health Questionnaire

Name (required)

Email (required)

Phone (required)

Gender

Occupation

Date of Birth

Weight:

Height:

BMI:

Which Procedure are you interested in?

Procedure Date:

Have you ever been diagnosed with Hepatitis?:

Do you refuse blood transfusions?:

Have you ever been diagnosed with Hiatal Hernia?:

Do you have any allergies?:

Do you have Type I Diabetes:

Do you have Type II Diabetes:

Have you been diagnosed with pregestational diabetes?

Do you suffer from any Heart Disease?

Do you have Asthma?

Do you suffer from High Blood Pressure?

Do you have any kidney or urinary disorder?

Do you suffer from any neurological condition?

Have you been diagnosed with Gallstones?

Have you had any gastric or duodenal ulcer?

Have you had any liver disorder?

Do you currently have anemia or any Blood imbalance?

Do you suffer from heartburn or reflux?

Are you receiving kidney dialysis treatments?

Do you have any additional medical condition to report to the surgeon?

Do you drink alcoholic beverages?:

Do you Smoke?

Do you use any recreational drugs?

List your current medications, reason and dosage:

Do you take any blood thinner?

Do you have previous surgeries?

At Bariatrik US, we are dedicated to providing exceptional care and support throughout your weight loss journey. We encourage you to take the first step by completing our secure online form. Rest assured, your personal information is protected by the highest standards of data security and confidentiality. Your privacy is our top priority, and we handle all the information you provide with the utmost care and discretion. Begin your transformation with confidence, knowing your details are safe with us.

Health Questionnaire

info@bariatrikus.com

info@bariatrikus.com

@bariatrik.us

Health Questionnaire

Transform Your Health with Bariatric Surgery Ready to take the next step? Chat with our expert team now and start your transformation today!