Application form for stomach reduction surgery

BMI calculator

Weight:	kg
Height:	cm

If your body mass index is 30 or more, doctors recommend that you take care of your health. One of the effective methods of weight loss is gastric bypass surgery. In our clinic, operations are not compensated, but payment is possible! Is stomach reduction the right way to lose weight for you, consult with bariatric surgeon prof. Antanas Mickevičius by filling out this form.

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APPLICATION FORM FOR BARIATRIC SURGERY - EN

"*" indicates required fields

General information

First name*

Last name*

Date of birth*

Gender*

Email*

Phone*

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*

Surgery

Reason

Date

Current medications

Medication / How often taken*

Medication / How often taken

Reason

Date started

Previous medications

Previous medications*

Medication / How often taken

Reason

Date started

Major illnesses you had

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

Prefered type of surgery*

Gastric bypass

Gastric sleeve

Gastric plication

Gastric balloon

Revisional surgery

Preffered surgery 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 Clinic (JSC Vivamedicus) and myself*

Yes

Date of filling out the form*

How did you hear about us?*

Consent*

I consent to NEWMAN Bariatric Clinic (JSC "Vivamedicus") collecting my personal data. More information Privacy Policy

Name

This field is for validation purposes and should be left unchanged.

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Application form

BMI calculator

APPLICATION FORM FOR BARIATRIC SURGERY - EN

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 surgery date

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