Español

Quick Links

Suscribe to our Yahoo Group

Suscribe to our Obesity Support Group.
Eligibility Questionnaire 1866-643-BAND (Toll Free)
Office: (619)209-7351
 

Contact Us

The information submitted by you is privileged and confidential,
Obesity Goodbye does not distribute or sell this information to 3rd parties, as it is used strictly for internal purposes.

 

Procedure:   Patient facilitator name:   Date of surgery:
 
Name:   E-mail:
 
*Telephones:
Home:   Cell:   *Emergency:
 
*Contact name in case of emergency  
 
Address:   City, State, Zip code:
 
Date of Birth:   *Age:   *Height:   *Weight:   *BMI:
 
Maximum Weight:   When?   *List all Medicine Allergies:
 

Any Medical/physical problems (i.e., sleep apnea, high blood pressure, diabetes, high cholesterol, blood diseases, neurological disorders, etc)?

  
No Do Not Know
If Yes, please list:  

  Are you currently taking any medications or herbal supplements?

  
No Do Not Know

If Yes, please list the name, dosage and reason for this medicine:

  

Is there any history in your family of diabetes, cancer and/or hypertension?

  
No Do Not Know
If Yes, please indicate which ones:  

Any  surgeries (i.e., gallbladder, appendix, hernia, heart, etc.)?

  
No Do Not Know
If Yes, please list:  

Do you have any adverse reaction to anesthesia?

 
No Do Not Know
If Yes, please indicate the reaction:  

Do you have dentures, dental implants, or caps?

 
No Do Not Know
If Yes, please indicate where:  

Do you have any children?

 
No

If so, how many?

 

Do you have heavy periods?

 
No

Do you smoke?

  
No

If yes how many cigarettes a day?

  

Do you drink?

  
No

If yes , how many?

  

Do you do drugs?

  
No

If yes, what kind & how often?

  
 
Pre-Operative Assessment
 
Patient Name   Age   Sex   Date
 
For the Following Questions, Please Indicate "Yes" "No" or "Do Not Know". Please answer all of the questions.
 
Do you currently take any of the following medications?
a) Aspirin (excedrin, anacin, bufferin)
No Do Not Know
b) Anticoagulants (blood-thinning medicine)
No Do Not Know
c) Propanol, Verapamil (heart rhythm medicines)
No Do Not Know
d) Diuretics (water pills)
No Do Not Know
e) Antihypertensive drugs (blood pressure pills)
No Do Not Know
f) Digitalis (heart pills)
No Do Not Know
g) Stereoids (prednisone, cortisone)
No Do Not Know
Have you ever been treated for cancer with chemotherapy or radiation therapy?  
No Do Not Know
If yes: when?  
Do you currently have any problems with your:
a) Liver (e.g. cirrhosis, hepatitis, yellow jaundice)
No Do Not Know
b) Kidneys (infection, stones, failure)
No Do Not Know
c) Spleen
No Do Not Know
d) Blood (anemia, leukemia)
No Do Not Know
Have you or anyone in your family ever had a serious bleeding problem?  
No Do Not Know
Have you ever had prolonged or unusual bleeding from tooth extractions,
cut, surgery or nosebleed?		  
No Do Not Know
Do your gums bleed when you brush your teeth?  
No Do Not Know
Are you pregnant?  
No Do Not Know
Is there any possibility that you are pregnant?  
No Do Not Know
Have been told you have diabetes?  
No Do Not Know
Do you wake up to urinate more than once at night?  
No Do Not Know
Do you have muscle cramps or pains?  
No Do Not Know
Do you have problems with your lungs or chest? (e.g., chest pain, skipped heart beats, high blood pressure, shortness of breath, emphysema, asthma, bronchitis)  
No Do Not Know
if yes please list:  
Do you have a cough, or cough frequently?  
No Do Not Know
Do you have epilepsy or suffer from fits or seizures?  
No Do Not Know
Do you have neck or back problems?  
No Do Not Know
Are you scheduled to have an operation?  
No Do Not Know
If Yes, what operation?  
Are you currently taking any medications?  
No Do Not Know
If Yes, please list:  
 
 
 
[ Back ]