Application form

Bariatric surgeon
Antanas Mickevičius MD, PhD

General information

Measures

Diet history

How long have you been overweight*

What have you done to try to lose weight?*

Are you a snacker?*

Are you a volume eater?*

Do you eat a lot of food containing sugar?*

Do you frequently eat fast food and/or drink carbonated beverages?*

What foods or drinks cause you digestive problems?*

Do you drink alcohol? If yes, please tell us how often and how much:*

Do you smoke? If yes, please tell us how often and how much:*

Do you have any other addictions?*

Personal Health

Do you experience shortness of breath with physical activity?*

Do you exercise regularly?*

Do you have or had asthma?*

Do you have thyroid problems?*

Do you have any allergies?*

Have you been diagnosed with fatty liver, cirrhosis, hepatitis or any other liver disease?*

Do you have indigestion or heart burn?*

Have you been diagnosed for lupus?*

Have you been diagnosed HIV positive?*

Family Health

Other (family member / type)

Previous surgeries

Surgery	Reason	Date

Current medications

Medication / How often taken	Reason	Date started

Previous medications

Medication / How often taken	Reason	Date started

Major illnesses you had

Illness / Date	Treatment / Outcome

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

Preferred type of surgery*

Preffered date

Surgery date*

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.*

Date of filling out the form*

I consent to NEWMAN Bariatric (UAB VIVAMEDICUS) for collecting my personal data for Privacy Policy

Bariatric surgeon
Antanas Mickevičius MD, PhD
General information
First name*
Last name*
Age*
Date of birth*
Gender*
E-Mail*
Phone No.*
Occupation*
Measures
Height, cm*
Weight, kg*
BMI*
Highest weight in life, kg*
Diet history
How long have You been overweight*
What have you done to try to lose weight?*
Are you a snacker?*
Are you a volume eater?*
Do you eat a lot of food containing sugar?*
Do you frequently eat fast food and/or drink carbonated beverages?*
What foods or drinks cause you digestive problems?*
Do you drink alcohol? If yes, please tell us how often and how much:*
Do you smoke? If yes, please tell us how often and how much:*
Do you have any other addictions?*
Personal Health
Diabetes (type / medication)*
Cancer (type)*
Overweight*
Obesity*
Heart disease (type)*
High blood pressure*
Gastric symptoms (type)*
Do you experience shortness of breath with physical activity?*
Do you exercise regularly?*
Do you have or had asthma?*
Do you have thyroid problems?*
Do you have any allergies?*
Have you been diagnosed with fatty liver, cirrhosis, hepatitis or any other liver disease?*
Do you have indigestion or heart burn?*
Have you been diagnosed for lupus?*
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)*
Other (family member / type)
Previous surgeries
*
Surgery Reason Date
Current medications
*
Medication / How often taken Reason Date started
Previous medications
*
Medication / How often taken Reason Date started
Major illnesses You had
*
Illness / Date Treatment / Outcome
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
Preferred type of surgery*
- Gastric bypass
- Gastric sleeve
- Gastric plication
- Gastric balloon
- Revisional surgery
Preffered date
Surgery date*
Date Format: DD slash MM 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*
Date Format: DD slash MM slash YYYY
*
- I consent to NEWMAN Bariatric (UAB VIVAMEDICUS) for collecting my personal data for Privacy Policy

Bariatric surgeon
Antanas Mickevičius MD, PhD

General information

Measures

Diet history

Personal Health

Family Health

Previous surgeries

Current medications

Previous medications

Major illnesses you had

Additional information

Prefered type of surgery

Preffered date

Bariatric surgeon
Antanas Mickevičius MD, PhD

General information

Measures

Diet history

Personal Health

Family Health

Previous surgeries

Current medications

Previous medications

Major illnesses You had

Additional information

Prefered type of surgery

Preffered date

24/7 Client Helpline:

Phone: +370 612 04 006
+WhatsApp +Viber

NEWMAN Bariatric
S. Žukausko str. 2B, Kaunas
LT-50118, Lithuania
I – V 09.00 – 18.00

Part of NEWMAN Clinic

NEWMAN Aesthetics
NEWMAN Vitamins

All rights reserved. NEWMAN Clinic

24/7 free patient helpline:

Phone: +370 612 04 006
+WhatsApp +Viber

NEWMAN Bariatric
S. Žukausko str. 2B, Kaunas
LT-50118, Lithuania
I – V 09.00 – 18.00

Part of NEWMAN Clinic

NEWMAN Aesthetic

NEWMAN Vitamins

All rights reserved. NEWMAN Clinic