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Body Art
BARIATRICS
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Name
Last Name
Email
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Phone
Edad
Birthday
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¿How did you know about us?
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Unit of measurement | Height and Weight
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Weight (Lbs)
Weight (Kg)
Height (ft)
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Height (Meters)
BMI (body mass index):
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Desired Procedure
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Mini Gastric Sleeve / Traditional Gastric Sleeve (VSG)
Mini gastric bypass / traditional gastric bypass (Roux-en-Y)
Endoscopic gastric sleeve (ESG)
Intragastric balloon
Another revision procedure
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Select if you have suffered or suffer from any of these diseases:
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Hypothyroidism
Diabetes
Hypertension
Cardiovascular diseases
Anemia
Thrombosis
High cholesterol
Osteoporosis
Neurological conditions
None of the above
Do you use tobacco, marijuana, electronic cigarettes?
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How often do you consume it?
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Do you consume alcoholic beverages?
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How often do you consume them?
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Are you currently taking any medications?
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Please indicate the name of the medication:
Indicate the dose of the medication:
Please indicate how often you take the medication:
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Are you currently taking a 2nd medication?
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Please indicate the name of the 2nd medication:
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Please indicate how often you take the 2nd medication:
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Are you currently taking a 3rd medication?
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Please indicate the name of the 3rd medication:
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Please indicate how often you take the 3rd medication:
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Are you currently taking a 4th medication?
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Please indicate the name of the 4th medication:
Indicate the dose of the 4th medication:
Please indicate how often you take the 4th medication:
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Please indicate how often you take the 4th medication:
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Name
Please indicate how often you take the 4th medication:
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Name
Have you been pregnant?
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How many pregnancies have you had?
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Indicate whether these pregnancies were natural, cesarean, abortions, spontaneous or induced abortions.
Indicate whether these pregnancies were natural, cesarean, abortions, spontaneous or induced abortions.
Have you had previous bariatric surgeries?
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What bariatic surgery(s) have you had?
Gastric sleeve
Gastric bypass
Intragastric Balloon
Other procedure
Please indicate the date(s) you had the surgery(s)
How much weight did you lose with the surgery(s) mentioned?
Did you regain any of that lost weight?
Did you suffer any complications after bariatric surgery?
Are you currently suffering from stomach reflux?
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Have you had previous surgeries other than bariatric surgeries?
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Indicate what other surgery(s) you have had with dates if possible.
Name each of your MEDICATION allergies:
Name each of your FOOD allergies or dietary restrictions:
Please leave any additional comments if you felt that you were not able to fully describe your medical history.
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