Application Form

BARIATRIC APPLICATION FORM

The risk of intervention is associated with the patient body constitution and negative factors he/she has been exposed to in the past. In order to determine those risk factors on time, please answer the following questions

GENERAL INFORMATION

MEASURES

DIET HISTORY

PERSONAL HEALTH

PREVIOUS SURGERIES

FAMILY HEALTH

CURRENT MEDICATIONS

PREVIOUS MEDICATIONS

MAJOR ILLNESSES YOU HAND

ADDITIONAL INFORMATION

PREFERED TYPE OF SURGERY

PREFERED DATE

First Name

Last Name

E-mail

Date of brith

Age

Phone No.

Occupation

Height, cm

Weight, kg

BMI

Highest weight in life, kg

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?

Diabetes ( type/medications )

Cancer ( type )

Overweight

Obesity

Heart disease ( type )

High bood 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?

Diabetes (Family member/type)

Cancer (Family member type)

Overweight (Family member)

Obesity (Family member/type)

Heart disease (Family member)

High blood pressure (Family member/type)

Other (Family member)

Surgery

Reason

Date

Medication / How often taken

Reason

Date started

Medication / How often taken

Reason

Date started

Illness / Date

Treatment / Outcome

Please list any additional information you believe would help us to form a better view of your current health condition

Gastric Bypass. Gastric Sleeve. Gastric Plication. Gastric Ballon. Revision Surgery

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 BALTICLINIC and myself.

Yes

Date of filling out the form

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