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+370 612 04006
ES
+370 648 25979
Part of the NEWMAN Clinic
NEWMAN Clinic
Healtcare services
NEWMAN Bariatric
Weight loss surgery
NEWMAN Vitamins
Quality vitamins and services
NEWMAN Aesthetic
Plastic and reconstructive surgery
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Hospital
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Weight Loss Treatments
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NEWMAN Clinic
NEWMAN Bariatric
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+370 612 04006
ES
+370 648 25979
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Application form
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APPLICATION FORM FOR BARIATRIC SURGERY - EN
"
*
" indicates required fields
General information
First name
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Last name
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Date of birth
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MM slash DD slash YYYY
Gender
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Email
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Phone
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Occupation
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Measures
Height, cm
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Weight, kg
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BMI
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Highest weight in life, kg
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Diet History
How long have you been overweight
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What have you done to try to lose weight?
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Are you a snacker?
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Are you a volume eater?
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Do you eat a lot of food containing sugar?
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Do you frequently eat fast food and/or drink carbonated beverages?
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What foods or drinks cause you digestive problems?
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Do you drink alcohol? If yes, please tell us how often and how much:
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Do you smoke? If yes, please tell us how often and how much:
*
Do you have any other addictions?
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Personal Health
Diabetes (type / medication)
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Cancer (type)
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Overweight
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Obesity
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Heart disease (type)
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High blood pressure
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Gastric symptoms (type)
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Do you experience shortness of breath with physical activity?
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Do you exercise regularly?
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Do you have or had asthma?
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Do you have thyroid problems?
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Do you have any allergies?
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Have you been diagnosed with fatty liver, cirrhosis, hepatitis or any other liver disease?
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Do you have indigestion or heart burn?
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Have you been diagnosed for lupus?
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Have you been diagnosed HIV positive?
*
Family Health
Diabetes (family member / type)
*
Cancer (family member / type)
*
Overweight (family member)
*
Obesity (family member / type)
*
Heart disease (family member / Type)
*
High blood pressure (family member / type)
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Other (family member / type)
*
Previous surgeries
Surgery
*
Surgery
Reason
Date
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Remove
Current medications
Medication / How often taken
*
Medication / How often taken
Reason
Date started
Add
Remove
Previous medications
Previous medications
*
Medication / How often taken
Reason
Date started
Add
Remove
Major illnesses you had
Major illnesses you had
*
Illness / Date
Treatment / Outcome
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Remove
Additional information
Please list any additional information you believe would help us to form a better view of your current health condition
*
Prefered type of surgery
Prefered type of surgery
*
Gastric bypass
Gastric sleeve
Gastric plication
Gastric balloon
Revisional surgery
Preffered date
Surgery date
*
MM slash DD slash YYYY
I confirm that I fully understand what personal data is being collected from me and for what reasons through this online form. I also confirm that I fully understand the confidentiality agreement between NEWMAN Bariatric (JSC Vivamedicus) and myself.
*
Yes
Date of filling out the form
*
MM slash DD slash YYYY
Consent
*
I consent to NEWMAN BARIATRIC (VIVAMEDICUS, UAB) collecting my personal data.
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