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    Medical History

    Date of Birth



    What procedure are you interested in?

    Are you interested in a particular bariatric surgeon? (If yes, please write his/ her name:)


    Mark if you suffer any ofthese symptoms:

    Have you been diagnosed with any ofthese medical conditions:


    List your prescribed medications and dose (including birth control and /or hormonal creams/pills/supplements) f you do not take any medications please write NO MEDICATIONS

    Allergies to medications: , if yes; please enlist the medications you are allergic to. If not, please write NO ALLERGIES

    Did you have Covid-19? If yes, were you hospitalized and or connected to a ventilator and for how long?

    Have you been vaccinated for COVID -19?

    Date of your last physical examination:

    Blood type:

    Have you ever had a blood transfusion?

    If yes, describe:

    Have you had any previous surgeries? If yes, describe:

    Do you use a CPAP MACHINE?


    Do you drink alcohol?

    Do you smoke tobacco? if yes how many cigarettes a day ?

    Do you chew tobacco?

    Do you currently use recreational or medicinal drugs?

    Have you ever been on treatment for drug/ alcohol abuse? if yes, describe and and provide dates of your lasttreatment.

    Do you exercise?

    Women Only

    Age at onset of menstruation

    Date of last menstruation

    Period every ___ days

    Heavy periods, irregularity, spotting, pain, or discharge?

    Number of pregnancies and Number of live births

    Are you pregnant or breastfeeding?

    Have you given birth in the last 12 months?

    Have you had a D&C, hysterectomy, or Cesarean?

    Any urinary tract, bladder, or kidney infections within the last year?

    Any blood in your urine?

    Any problems with control of urination?

    Any hot flashes or sweating at night?

    Do you have menstrual tension, pain, swelling, irritability, etc.?

    Did you recently have breast, lump or nipple discharge?

    Date of last pap and rectal exam?