Patient Questionnaire

General Information

First Name Last Name Date of Birth

Male Female

Address City Province Postal Code Country Occupation

Contact Information

Phone Cell Work Fax Email Other

Insurance Information

Health Insurance Other Insurance

References

Doctor Patient Internet Other

Body Mass Index

Weight Height BMI (calculate)

Obesity History

Since When

List the diets followed in the past and the respective results for each of them.

Medical History

Sleep Apnea Asthma Depression Diabetes Dyslipidemia / Hypercholesterolemia Hypertension Gallbladder Stones Cardiac Disease Hepatic Disease Crohn’s Disease / Ulcerative Colitis Musculoskeletal Disease Other Pulmonary Disease Stomach Ulcers Gastric Reflux Disease Blood Disorders Phlebitis Thrombosis Pulmonary Embolus Varicoses

Other(s) Family History

Life Habits

Smoking Alcohol Allergies Other Habits

Current Medication

Anticoagulants Antidepressants Sleep Apnea: CPAP Asthma Cholesterol Diabetes Diet Oral Hypoglycemiants Insulin Hypoglycemiants Cardiac Medication Other

Surgical Indications

BMI > 40 BMI > 35 With Comorbidity

List any previous surgery you've had: Do you think you are a candidate for the surgery? yes no Are you aware of the different surgical options? yes no