Medical History Date of Birth EMERGENCY CONTACT INFO SURGERY OF INTEREST What procedure are you interested in? Are you interested in a particular bariatric surgeon? (If yes, please write his/ her name:) MEDICAL CONDITIONS: Mark if you suffer any ofthese symptoms: GERDHeartburnReflux Have you been diagnosed with any ofthese medical conditions: High Blood PressureDiabetesPre-DiabetesAnemiaAny Other blood related diseaseHeart disease *PLEASE DESCRIBE YOUR MEDICAL CONDITION: 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? YesNo If yes, describe: Have you had any previous surgeries? If yes, describe: Do you use a CPAP MACHINE? YesNo LIFE STYLE : Do you drink alcohol? HeavyModerateSocial DrinkerNo Do you smoke tobacco? if yes how many cigarettes a day ? Do you chew tobacco? YesNo Do you currently use recreational or medicinal drugs? YesNo Have you ever been on treatment for drug/ alcohol abuse? if yes, describe and and provide dates of your lasttreatment. Do you exercise? YesNo 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?
