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NEWMAN Bariatric
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+370 612 04006
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+370 648 25979
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Application form
APPLICATION FORM FOR BARIATRIC SURGERY - EN
"
*
" indicates required fields
General information
First name
*
Last name
*
Date of birth
*
MM slash DD slash YYYY
Gender
*
Email
*
Phone
*
Occupation
*
Measures
Height, cm
*
Weight, kg
*
BMI
*
Highest weight in life, kg
*
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?
*
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?
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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?
*
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?
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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
Add
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
Add
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 surgery 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 Clinic (JSC Vivamedicus) and myself
*
Yes
Date of filling out the form
*
MM slash DD slash YYYY
How did you hear about us?
*
Choose an answer
I purposefully searched through Google
I accidentally posted a banner ad online
I saw it on Facebook
I saw it on Instagram
Recommended
I found you on https://www.topdoctors.co.uk/
Other
Consent
*
I consent to NEWMAN Bariatric Clinic (JSC "Vivamedicus") collecting my personal data. More information
Privacy Policy
Phone
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