Bariatric Surgery Health Questionnaire
We make getting started as easy as possible for our patients. Please take 5 minutes to complete our health questionnaire so Dr. Illan and our medical team can review it and approve your weight loss surgery.

Please Note: When you submit your questionnaire, you can rest assured that your information is protected by one of the most trusted names in internet security and that all information submitted via our web forms is transmitted privately and safely.
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Which Weight Loss Surgery would you prefer? *


 
What date would you like to schedule your {{answer_67697878}}? *

 
Contact Information

Please provide us with your contact information
 
What is your first name? *

 
Hey {{answer_67634679}}, nice to meet you.
What's your last name? *

 
Street Address

 
City

 
State

 
Postal Code

 
Phone

Home number or primary phone number with area code
 
Cell phone

Mobile number with area code
 
Do You Have a Passport/Passport Card?

     
 
Personal Information

 
How old are you?

 
Date of Birth

 
Occupation

 
Marital Status


 
Language Spoken

 
Diet History

 
What kind of diets have you carried out and for how long?

 
Are you on any special diet (Vegan, Vegetarain)?

 
Do you have any food allergies (Lactose Intolerance)?

 
Appetite Suppressant (If yes duration):

 
Any other drug treatment (If yes duration):

 
Did other events lead to weight gain (If yes explain):

 
Alcohol and Smoking

 
Do you drink Alcohol?

     
 
How many days do you drink per week?

 
How many standard glasses do you drink a day?

 
Do you smoke?

     
 
How many per day and for how long?

 
Have you stopped smoking? When?

 
Medical History

 
Height

 
Weight

 
Allergies (Please list all)

 
Have you had any of these problems in the past?


 
Specify Pregnancies/Births/Abortions (Children Ages)

 
Surgical History Details

Please list any surgeries (operations) you have had
 
Diabetes Medication

 
Diabetes while pregnant

 
Respiratory Breathing Problems (If yes explain)

 
Arthritis or joint pain (If yes explain)

 
Back Pain (If yes explain)

 
Kidney or Urinary Disorder (If yes explain)

 
Neurological (If yes explain)

 
Psycological nervous disorder (If yes explain)

 
Gallstones Medication

     
 
Gastric or duodenal ulcer (If yes explain)

 
Reflux or Heartburn (If yes explain)

 
Hepatitis or Liver Disease (If yes explain)

 
High Blood Pressure (If yes explain)

 
Heart Disease Medication

     
 
High Cholesterol Medication

     
 
Anemia or Bleeding disorder (If yes explain)

 
Thrombosis or Clotting Disorder (If yes explain)

 
Varicose Veins or Leg Swelling (If yes explain)

 
Eczema or skin condition (If yes explain)

 
Rhinitis

     
 
Details of major illness or problems

 
How many hours of sleep do you get a night?

 
Does anything keep you awake at night (If yes explain)

 
Do you feel sleepy during the day?

     
 
How often would you sleep more than 8 hours in total?

 
How often do you doze off while driving?

 
Job level of activity

 
Medication for psyciatric disorder (If yes explain)

 
List all Medications taken for the last past 12 months

 
Migraine Medication

     
 
Drugs for epilepsy (If yes explain)

 
Cortisone (If yes explain)

 
Hormones (If yes explain)

 
HRT (If yes explain)

 
Do you have difficulty in swallowing (If yes explain)

 
Do you suffer from recurring sore throat (If yes explain)

 
Have you ever had problems with anesthesia?

     
 
Last question, {{answer_67634679}}! How did you hear about Dr. Illan and BariatricPal Hospital MX? *

{{answer_67634679}}, thank you for completing your weight loss surgery questionnaire for {{answer_67697878}}! Dr. Illan and his medical team will review your information and we will reach out to you within 24 hours.

If you have any questions, please feel free to contact us Toll-Freee at (844) 957-3325 or via email TeamMX@BariatricPal.com .

We look forward to seeing you soon!