Questionnaire

Medical Questionnaire

Personal information

First Name *

Last Name *

Email *

Phone number

City

State / Province / Region

Date of birth *

Height (ft / in) *

Weight (lbs.) *

Do you have any allergies? *

Allergies

Surgery

Which kind of surgery are you interested in?

Have you had a weight loss surgery before? *

Any previous open abdominal surgery? *

Do you take any medication? *

Do you have heart conditions? *

Do you have reflux or indigestion? *

Comments or questions

I agree to the Terms of Service: I understand that full disclosure is necessary for my medical safety, I have completed the medical history to the best of my knowledge, and have answered these questions honestly.

Questionnaire

Medical Questionnaire

Datos de contacto

Enlaces útiles

Entrada reciente

Servicios

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