Health Questionnaire

Contact Information

Name (required)
Email (required)

Phone (required)
Gender
Occupation
Date of Birth
Who Referred You? (Influencer/Referrer Name)

Current Weight

Weight:
Height:
BMI:

Surgery Preferences

Which Procedure are you interested in?
Procedure Date:
Prefered Surgeon:

Health History

Diseases

Have you ever been diagnosed with Hepatitis?:

Have you ever been diagnosed with HIV?:
Do you refuse blood transfusions?:
Have you ever been diagnosed with Hiatal Hernia?:
Do you have any allergies?:

What type of 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?

Please Explain:

Do you have Asthma?

Please Explain:

Do you suffer from High Blood Pressure?

Please Explain:

Do you have any kidney or urinary disorder?

Please Explain:

Do you suffer from any neurological condition?

Please Explain:

Have you been diagnosed with Gallstones?

Please Explain:

Have you been diagnosed from any nervous or psychological disorder?

Please Explain:

Have you had any gastric or duodenal ulcer?

Please Explain:

Have you had any liver disorder?

Please Explain:

Do you currently have anemia or any Blood imbalance?

Please Explain:

Do you suffer from heartburn or reflux?

Please Explain:

Was your gallbladder ever removed?

Are you receiving kidney dialysis treatments?

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

Disease:
Diagnosed Date:
Treatment:
Outcome:

Medications & Lifestyle

Do you drink alcoholic beverages?:

How often:

Do you Smoke?

How often:

Do you use any recreational drugs?

How often:

List your current medications, reason and dosage:
Do you take any blood thinner?

Which and dosage:

Previous Surgeries

Do you have previous surgeries?

Procedure:
Procedure Date:
Reason:
Procedure Type:

Contact Information

Current Weight

Surgery Preferences

Health History

Diseases

Medications & Lifestyle

Previous Surgeries

Contact

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