Health Questionnaire

Start Your Transformative Journey Now..

Take the first, crucial step on your weight loss journey by filling out our Health Form. These questions are critical for our surgeons to decide what weight loss surgery option is best for you. Filling out this form, there is no obligation. This form is only to help guide you in the right direction for your journey. Please fill this form out accurately and in its entirety.

CONTACT INFORMATION

Name(Required)

First Last

Email Address(Required)

Phone Number(Required)

Preferred Method of Contact

Qualifying Details

This information is needed to qualify you for weight loss surgery

Date(Required)

Age(Required)

Gender

Current Weight ( Specify Units - Kilograms / Pounds )(Required)

Height ( Specify Units - Feet / inches/ centimeters )

Surgery Interest

How Far Are You In The Process(Required)

List Your Questions Here

Surgery Interest

Additional Procedures of Interest

Estimated Surgery Date

Medical History

This information is needed to qualify you for weight loss surgery and to provide a safe surgery if you decide to schedule surgery with our team.
Please review each medical condition, if you have a history of any of the following symptoms or conditions please specify.

Previous Weight Loss Surgery(Required)

Past Weight Loss Surgery: Types & Dates

Gastrointestinal Conditions(Required)

GERD / Heartburn Symptoms(Required)

Heart Problems(Required)

Respiratory Conditions(Required)

Urinary Conditions(Required)

Muscular Conditions(Required)

Neurological Conditions(Required)

Endocrine Conditions(Required)

Blood Disorders(Required)

Cancer(Required)

Have You Ever Had Hepatitis?(Required)

HIV(Required)

Did you refuse blood transfusion in the past?

IMPORTANT - Previous Surgeries? (List if Applicable)

Date - Surgery Type - Any Complications?

Psychiatric Treatment Type & Dates (List if Applicable)

Other Medical Conditions Not Listed? (List if Applicable)

Medications or Supplements? (List if Applicable)

Allergy Details

This information is needed to provide a safe surgery if you decide to schedule surgery with our team.

Allergic to Latex?

Allergic to Surgical Tape?

List All Other Allergies

Dietary Information

Indicate which of these items you have used in the last 30 days. Skip this section if it does not apply.

alcohol products
caffeine products
nicotine products
marijuana products
hormones (including birth control)
aspirin products

List Products if Applicable

Mailing Address

This is not a required field:
Mailing address allows our t eam to send you educational resources, swag, and allows us to plan for local events in your local area.

Address

Address Line 1

Address Line 2

Address Line 2 City ZIP / Postal Code Country

Comment

How Did You Hear About Us?

Name or Referrer

Other Source of Referral

Anything Else You Want To Add?

Terms & Conditions

These questions are critical for our surgeons to decide what weight loss surgery option is best for you. Filling out this form, there is no obligation. This form is only to help guide you in the right direction for your journey. Please fill this form out accurately and in its entirety.

SELF DECLARATION

The information I provided in this health questionnaire is truthful, honest, and accurate. I understand that if I fail to tell the truth, there can be serious consequences including, but not limited to poor results, complications and my physical well-being.

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