Gastric Bypass Questionnaire

Home » Gastric Bypass Questionnaire

Name

Phone

Describe any past and current Illness history:*

What is your current weight and BMI?*

Briefly describe your daily/past eating and exercise patterns.*

Describe your weight history from childhood throughout your adulthood.*

Describe all Commercial Weight Loss Programs you have partaken in i.e., date started, dates stopped, time used, pounds lost, and results.*

Describe any family history of obesity ( family i.e., parents, siblings grandparents only):*

List any and all allergies:*

Past Medical History Surgery:*

Describe your social history as it relates to the following:

Alcohol Abuse*

Substance Abuse*

Tobacco Abuse*

Domestic Abuse*

Why are you pursuing this surgery/procedure?*

Have a question or need help? Fill out our form now. Our team is here to assist you. Contact us today!

Set your categories menu in Header builder -> Mobile -> Mobile menu element -> Show/Hide -> Choose menu

Create your first navigation menu here

Start typing to see posts you are looking for.