Contact Information Name (required) Email (required) Phone (required) Gender MaleFemale Occupation Date of Birth Who Referred You? (Influencer/Referrer Name) Current Weight Weight: Height: BMI: Surgery Preferences Which Procedure are you interested in?Gastric SleeveSingle Incision Gastric SleeveGastric BypassMini Gastric BypassIntragastric BalloonDuodenal SwitchSADI-SRevision (Lap Band to Gastric SleeveRevision (Lap Band to Gastric Bypass)Revision (Lap Band to Mini Gastric Bypass)Revision (Gastric Sleeve to Gastric Bypass)Revision (Gastric Sleeve to Duodenal Switch)Revision Gastric Sleeve to Mini Gastric Bypass)Revision (Gastric Bypass to Gastric Bypass) Procedure Date: Prefered Surgeon: Dr. Louisiana ValenzuelaDr. Carlos Mora Health History Diseases Have you ever been diagnosed with Hepatitis?: NoYes Have you ever been diagnosed with HIV?:NoYes Do you refuse blood transfusions?:NoYes Have you ever been diagnosed with Hiatal Hernia?: YesNo Do you have any allergies?: NoYes [group Allergies]What type of Allergies?[/group] Do you have Type I Diabetes: NoYes Do you have Type II Diabetes: NoYes Have you been diagnosed with pregestational diabetes? NoYes Do you suffer from any Heart Disease? NoYes [group heart-disease-treatment]Please Explain: [/group] Do you have Asthma? NoYes [group asthma-treatment]Please Explain: [/group] Do you suffer from High Blood Pressure? NoYes [group high_blood_pressure]Please Explain: [/group] Do you have any kidney or urinary disorder? NoYes [group kidney-disorder]Please Explain: [/group] Do you suffer from any neurological condition? NoYes [group neuro-disorder]Please Explain: [/group] Have you been diagnosed with Gallstones? NoYes [group gallstonesgr]Please Explain: [/group] Have you been diagnosed from any nervous or psychological disorder? NoYes [group psychogr]Please Explain: [/group] Have you had any gastric or duodenal ulcer? NoYes [group ulcergr] Please Explain: [/group] Have you had any liver disorder? NoYes [group livergr] Please Explain: [/group] Do you currently have anemia or any Blood imbalance? NoYes [group anemiagr] Please Explain: [/group] Do you suffer from heartburn or reflux? NoYes [group refluxgr] Please Explain: [/group] Was your gallbladder ever removed? NoYes Are you receiving kidney dialysis treatments? NoYes Do you have any additional medical condition to report to the surgeon? NoYes [group Illnessgr]Disease: Diagnosed Date: Treatment: Outcome: [/group] Medications & Lifestyle Do you drink alcoholic beverages?: NoYes [group alcoholicgr]How often: [/group] Do you Smoke? NoYes [group smoke-text]How often: [/group] Do you use any recreational drugs? NoYes [group drugs-text]How often: [/group] List your current medications, reason and dosage: Do you take any blood thinner? NoYes [group blood-thinners] Which and dosage: [/group] Previous Surgeries Do you have previous surgeries? NoYes [group previous-surgeriesgr] Procedure: Procedure Date: Reason: Procedure Type: OpenLaparoscopic [/group] Δ
