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Our Health Questionnaire
"
*
" indicates required fields
Desired surgery date
*
MM slash DD slash YYYY
Surgery Type
*
- Select -
Gastric Sleeve
Gastric Bypass
Mini Gastric Bypass
SADIS
Revision Band to Sleeve
Revision Band to Bypass
Revision Band to Mini Bypass
Revision Sleeve to Bypass
Revision Sleeve to Mini Bypass
Revision Gastric Bypass
Intragastric Ball
Additional Procedure
*
- Select -
Gallbladder removal
Hiatal hernia repair
Hernia repair
Other
None
Please describe your desired procedure
*
Full legal name
*
First Name
Last Name
Address
*
Street Address
City
*
Country
*
USA
México
Canada
Other
Enter your country
*
State
*
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Guam
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New Hampshire
New Jersey
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
*
- Select -
Aguascalientes
Baja California
Baja California Sur
Campeche
Chiapas
Chihuahua
Coahuila
Colima
Durango
Guanajuato
Guerrero
Hidalgo
Jalisco
Mexico
Mexico City
Michoacán
Morelos
Nayarit
Nuevo León
Oaxaca
Puebla
Querétaro
Quintana Roo
San Luis Potosí
Sinaloa
Sonora
Tabasco
Tamaulipas
Tlaxcala
Veracruz
Yucatán
Zacatecas
Province / Territory
*
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Yukon
Nunavut
Zip Code
*
Gender
*
- Select -
Male
Female
Date of Birth
*
MM slash DD slash YYYY
Age
*
Height (Feet)
*
Enter the feet part of your height. Example: If you are 5' 7" enter 5
Height (Inches)
*
Enter the inches part of your height. Example: If you are 5' 7" enter 7
Weight (Pounds)
*
Height (cm)
*
Weight (kg)
*
BMI
BMI
Email
*
Cell Phone
*
Home Phone
Occupation
Facebook URL
How did you find us?
*
- Select -
A friend
Google
Yahoo
Facebook
Youtube
Online Forum
Instagram
Tik Tok
Dr Edwin Guerrero
Other
How would you prefer to be contacted?
Email
SMS
WhatsApp
Telephone call
Other
By which other means do you prefer to be contacted
*
Your Personal Statement
*
Tell us in your own words, why you want to have bariatric surgery.
Emergency Contact
Emergency Contact Person
*
First and Last Name
Emergency Contact Phone
*
Allergies
Tell us if you are allergic to the following:
Allergic to any medication?
*
Yes
No
Allergic to surgical tape?
*
Yes
No
Allergic to latex?
*
Yes
No
Allergic to Iodine?
*
Yes
No
Allergic to any food?
*
Yes
No
If yes to any of the above, please explain
Smoking & Alcohol
Do you currently smoke?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Past Surgery History
Have you ever had bariatric surgery?
*
Yes
No
If yes, list type of bariatric surgery and date
Have you ever had any other type of surgery?
Yes
No
List any past surgeries (date and type of surgery)
Medical History
When did you start to be overweight?
*
Childhood
Puberty
Adulthood
After traumatic event
After pregnancy
Have you been diagnosed with Hepatitis B?
*
Yes
No
Have you been diagnosed with Hepatitis C?
*
Yes
No
Have you been diagnosed with HIV?
*
Yes
No
Have you ever had heart problems? If yes, describe below.
*
Yes
No
Describe heart problems
Do you have a pace maker?
*
Yes
No
Do you use a CPAP or BiPAP machine?
*
Yes
No
Do you refuse blood transfusion?
*
Yes
No
Check all that you have been diagnosed with
*
None
Anemia (Iron Deficient)
Anemia (Vitamin B12 Deficient))
Anxiety
Arthritis, joint pain
Asthma
Blood Clots
Chest pain or agina
Crohn's disease
Chronic obstructive pulmonary disease/COPD (Emphysema)
Depression
Diabetes
Embolism
Fatty liver disease
Gallbladder trouble
Gastroesophageal reflux disease/GERD (Heart burn or indigestion)
Heart attack
Heart Disease
Heart failure
Hernia
High cholesterol
Hypertension (high blood pressure)
Irritable bowel syndrome
Lupus
Polycystic ovarian syndrome (PCOS)
Sleep apnea
Stomach ulcers
Thyroid disease
Were you ever diagnosed with Cancer?
*
Yes
No
If yes, what kind of Cancer do you have a history with?
What year did you have Cancer?
How did you treat your Cancer?
Surgical
Radiation
Chemotherapy
Any previous or current conditions of Epilepsy?
*
Yes
No
If yes, explain your Epilespy:
Any previous or current Psychiatric treatment?
*
Yes
No
If yes, explain your Psychiatric treatment:
Only for Women
Date of menstrual cycle:
MM slash DD slash YYYY
Your last menstrual cycle
Do you use any hormonal contraception (ex: birth control)?
Yes
No
List pregnancies, date and outcome (ex: full term, premature, C-section, miscarriage):
Medications
Are you taking any blood thinning medication (ex: Heparin, Coumadin, Warfarin, Plavix)?
*
Yes
No
If yes, list any blood thinning medication you're currently taking:
Are you taking any medications that have Aspirin in them?
*
Yes
No
If yes, list them:
List current medications you take on a regular basis (name, dosage, frequency):
Review of Systems
Constitutional Symptons
*
None
Fever
Weight loss
Weight gain
Fatique
Malaise
Eyes
*
None
Dry eyes
Red eyes
Painful eyes
Change in vision
Malaise
Heart
*
None
Chest pain
Chest pressure
Swelling feet/legs
Palpitations
Murmur
Waking up short of breath
Lungs
*
None
Wheezing
Cough
Sputum
Shortness of breath
With exertion
Stomach and Intestines
*
None
Heart burn
Acid Reflux
GERD
Nausea
Vomiting
Abdominal pain
Frequent constipation
Frequent diarrhea
Hemorrhoids
Kidneys and Bladder
*
None
Impotence
Difficulty with urination
Abnormal vaginal bleeding
Arising at night to urinate
Pain or burning on urination
Bladder incontinence
Muscle and Skeleton
*
None
Joint pain
Muscle pain
Joint swelling
Back pain
Brain and Nerves
*
None
Weakness
Tremor
Numbness
Incoordination
Fainting
Depression
Anxiety
Headaches
Glands
*
None
Excessive throat
Low blood sugar
High blood sugar
Low blood pressure
High blood pressure
Breasts
*
None
Pain
Lump/mass
Nipple retraction
Discharge
Is there anything related to your medical history that has not been covered? Please indicate:
*
Do you have any questions for your surgeon or medical team? Please indicate:
*
Do you have any physical limitations that require the use of:
*
None
Prosthesis
Crutches
Wheelchair
Date
MM slash DD slash YYYY
Print Name
*
First
Last
Signature
Comments
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First
Last
Email
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Phone
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City
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Type of Surgery
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Gastric Sleeve
Gastric Bypass
Mini Gastric Bypass
Revisional Surgery
SADIS Surgery
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Email
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