Home Form Form Name(Required) Last Name(Required) Sex(Required) M F Date Of Birth(Required) YYYY dash MM dash DD Marital Status(Required)Marital StatusSinglePartneredMarriedSeparatedDivorcedWidowedCellphone(Required)How Did You Find Us?How Did You Find Us?Referred by Dr.Referred by PatientGoogleInstagramYoutubeSurgicoordinatorRealsefWhatclinicPressDr. Name(Required) Patient Name(Required) Address(Required) Email(Required) Close Contact Person(Required) Relationship(Required) Phone(Required)PERSONAL HEALTH HISTORYList Any Medical Problems, Diseases That Other Doctors Have Diagnosed(Required)Prior Surgeries or HospitalizationsYear Reason Hospital Year Reason Hospital Year Reason Hospital Have You Ever Had A Blood Transfusion?(Required) Yes No Any Drugs That You Use Food and Drugs Allergies HEALTH HABITS AND PERSONAL SAFETYExercise(Required) Sedentary (No Exercise) Mild Exercise Occasional Vigorous Exercise Regularly Vigorous Of Meals You Eat In An Average Day?(Required)What Weight Loss Program Was The Most Effective In You? Why It Failed? My Overweight Is Because Frequency Snacking I Get Up To Eat At Night I Eat A Lot I Eat Junk Food I Like To Eat Until I Feel Totally Full That I Can Not Anymore Much Soda And Sugary Drinks / Juices I Eat And Then I Vomit To Be Able To Continue I Skip Meals, Not Breakfast When I'm Sad, I Eat More Anxiety Desserts and Sugar A Lot Of Alcohol Do You Drink Alcohol?(Required) Yes No How Many Drinks Per Week?(Required)Are You Concerned About The Amount You Drink?(Required) Yes No Do you use Cigarrillos, Vapes o E-Cigarettes?(Required) Yes No Occasionally Do You Currently Use Recreational Or Street Drugs?(Required) Yes No Which?(Required) Are You Sexually Active?(Required) Yes No Are You Trying For A Pregnancy?(Required) Yes No Your Preference Is(Required) Heterosexual Homosexual Bisexual Transgender List Contraceptive Or Barrier Method Used(Required) MENTAL HEALTHAre You Happy?(Required) Yes No Does that sadness last more than 2 weeks?(Required) Yes No Do You Feel Depressed?(Required) Yes No How In Your Self Esteem?(Required)How In Your Self Esteem?HighLowFluctuatingIs Stress A Major Problem For You?(Required) Yes No Have You Felt Guilty For Being Obese?(Required) Yes No Have You Ever Attempted Suicide?(Required) Yes No Have You Ever Been To A Counselor?(Required) Yes No Why Did I Decide To Consult To Lower Weight?What Will Be Different If I Do This Surgery?How Will This Surgery Benefit?Calculate IBM(Required) Lbs/In Kg/Cm Weight (Lbs)(Required)Height (Ft)(Required)Height (In)(Required)BMI(Required)Weight (Kg)(Required)Height (Cm)(Required)BMI(Required)
