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GASTRIC SLEEVE
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GASTRIC BYPASS
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ANTIREFLUX SURGERY
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PERSONAL HEALTH HISTORY
Do you have diabetes?
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Are you Hypertensive?
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Have you had heart attacks?
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Do you have any muscle pain?
(Required)
Yes
No
Do you suffer from Venous Insufficiency?
(Required)
Yes
No
Are you pregnant or lactating?
(Required)
-
No
Pregnant
Breastfeeding
Have you had surgery or been hospitalized previously?
(Required)
Yes
No
Please specify your previous surgery / hospitalization
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Any other Medical condition?
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No, I don't have any other medical condition
Metabolic Syndrome
Gastric Reflux
High Blood Pressure
Depression
Sleep Apnea
Polycystic Ovary Syndrome (PCOS)
Other (specify later)
Please specify your other medical condition
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Medicines that you take
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Are you allergic to any medications or foods?
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To which?
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Calculate BMI (Body Mass Index)
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Pounds / Inches
Kilograms / Centimeters
Weight (Lbs)
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Height (Ft)
(Required)
Height (In)
(Required)
BMI
(Required)
Weight (Kg)
(Required)
Height (Cm)
(Required)
BMI
(Required)
Procedure you want to perform.
(Required)
-
GASTRIC SLEEVE
ENDOSCOPIC SLEEVE
ALLURION GASTRIC BALLOON (PILL)
GASTRIC BYPASS
SADIS
ANTIREFLUX SURGERY
REVISION SURGERY FOR REGANANCE
CONSULTATION WITH THE DOCTOR
GALL BLADDER SURGERY
I still don't know, could you explain to me?
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Burundi
Cabo Verde
Cambodia
Cameroon
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Chad
Chile
China
Christmas Island
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Congo, Democratic Republic of the
Cook Islands
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Email
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PERSONAL HEALTH HISTORY
Do you have diabetes?
(Required)
Yes
No
Please specify your type of Diabetes
(Required)
-
Pre-diabetes
Diabetes Type 1
Diabetes Type 2
Are you Hypertensive?
(Required)
Yes
No
Have you had heart attacks?
(Required)
Yes
No
Do you have any muscle pain?
(Required)
Yes
No
Do you suffer from Venous Insufficiency?
(Required)
Yes
No
Are you pregnant or lactating?
(Required)
-
No
Pregnant
Breastfeeding
Have you had surgery or been hospitalized previously?
(Required)
Yes
No
Please specify your previous surgery / hospitalization
(Required)
Any other Medical condition?
(Required)
No, I don't have any other medical condition
Metabolic Syndrome
Gastric Reflux
High Blood Pressure
Depression
Sleep Apnea
Polycystic Ovary Syndrome (PCOS)
Other (specify later)
Please specify your other medical condition
(Required)
Medicines that you take
(Required)
Are you allergic to any medications or foods?
(Required)
Yes
No
To which?
(Required)
Calculate BMI (Body Mass Index)
(Required)
Pounds / Inches
Kilograms / Centimeters
Weight (Lbs)
(Required)
Height (Ft)
(Required)
Height (In)
(Required)
BMI
(Required)
Weight (Kg)
(Required)
Height (Cm)
(Required)
BMI
(Required)
Procedure you want to perform.
(Required)
-
GASTRIC SLEEVE
ENDOSCOPIC SLEEVE
ALLURION GASTRIC BALLOON (PILL)
GASTRIC BYPASS
SADIS
ANTIREFLUX SURGERY
REVISION SURGERY FOR REGANANCE
CONSULTATION WITH THE DOCTOR
GALL BLADDER SURGERY
I still don't know, could you explain to me?
Probable date of the procedure.
(Required)
YYYY slash MM slash DD
Check this if you would like to be included in our newsletter:
Yes, please include me
CLOSE
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