Application form

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 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.*

Yes

Date of filling out the form*

Consent*

I consent to NEWMAN BARIATRIC (VIVAMEDICUS, UAB) collecting my personal data. Privacy policy

Comments

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