BARIATRIC SURGERY FORM

Personal informations
Civility*
LAST NAME AND SURNAME*
First Last
DATE OF BIRTH*
Date Format: DD slash MM slash YYYY
Email*
Phone*
Medical information
Desired intervention*
Your current weight (in Kg)*
What maximum your maximum weight reached? (in kg)*
Your Height (in cm)*
Waist size
Your waist measurement (in cm)*
Duration of evolution of obesity*
What are your eating habits?*
- Mostly Sweet
- Mostly Salty
- Salty and sweet
- Fatty meals (Fast Food, etc.)
Do you consume sweetened liquids?
- Not often
- Yes
- No
Do you eat large meals often?*
- Not often
- Yes
- No
Do you snack?*
- Not often
- Yes
- No
What do you eat between meals?*
Do you drink alcohol in large quantities?*
- Not often
- Yes
- No
How many meals a day do you eat? and at what time of day?*
Other comments on your eating habits? Please specify*
Do you have associated diseases (diabetes, hypertension, coronary insufficiency, endocrine diseases, joint diseases, sleep apnea, respiratory diseases, cancers, infertility, psychiatric diseases, others…)? Please specify*
Do you have any digestive diseases (gastroesophageal reflux disease, ulcer, cirrhosis, Crohn's disease, tumours, other…)? Please specify*
Do you take long-term medication? Please specify*
Do you have any allergies (medicinal, other…)? Please specify*
Have you ever had any surgery? thank you for specifying (nature, by which way ..)*
Have you ever had surgery for obesity? Please specify (date, nature, approach, result, complications, etc.)*
Is obesity hereditary? Please specify*

BARIATRIC SURGERY FORM

Personal informations

Medical information

BARIATRIC SURGERY FORM