Prague Beauty, Bariatric Surgery


MEDICAL QUESTIONNAIRE

Personal Details

Address

Surgery

Height & Weight


feet & inches
centimetres
← OR →
stones & pounds
kilograms
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Allergies

Are you allergic?

Medical Condition

Anaemia / Blood Disorders
Asthma
Chronic Pain
Chronic Pulmonary Disease
Deep Venous Thrombosis
Depression
Diabetes
Does your Diabetes medication contain an active substance of Metformin?
(e.g. Fortamet, Glucophage, Glumetza, Riomet, etc.)
Endocrine Disease
Epilepsy / Convulsions
High Cholesterol
HIV positive
Hypertension
Infectious Disease
Ischemic Heart Disease / Myocardial Infarction
Liver Disease
Neurology Disorders
Mental Illness
Peptic Ulcer / Gastric – Duodenal
Reflux / GORD (Heartburn)
Sleep Apnea
Other condition

Previous Surgeries

Previous surgery

Lifestyle

Smoker?
Alcohol?
Addiction?