Bariatric Medical File

Bariatric Surgery Form

Full Name*

Date of birth *

Country of Residence*

Phone Number*

Email *

Desired Procedure(s)*

Your Current Weight*

Maximum Weight Reached*

Your Height (in cm)*

Your Waist Circumference (in cm)*

Duration of Obesity*

What are your eating habits (sweet, salty, large meals, snacking, alcohol, sugary drinks, etc.)?*

Do you have any associated medical conditions (Diabetes, Hypertension, coronary insufficiency, endocrine diseases, joint diseases, sleep apnea, respiratory diseases, cancers, infertility, psychiatric illnesses, others...)? Please specify.*

Do you have any digestive diseases (gastroesophageal reflux, ulcer, cirrhosis, Crohn's disease, tumors, others...)? Please specify.*

Are you on any long-term medication? Please specify.*

Do you have any allergies (medication, others...)? Please specify.*

Have you had any previous surgical procedures? Please specify (type, method, etc.).*

Have you had any previous surgical procedures for obesity? Please specify (date, type, method, result, complications, etc.).*

Family Medical History*

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