AC Renew Bariatrics -

Renew Bariatrics - Medical Questionnaire

Surgery Type Your Interested

General:

Do you use a B-PAP or C-PAP while you sleep?

Yes

No

Do you consume Tobacco / Nicotine?

Yes

No

Do You Consume Alcohol?

Yes

No

Do You Use Recreational Drugs?

Yes

No

If Recreational Drug use, please explain:

Medication:

List all medications

Do You, or have you in the past taken Blood Thinners? (If yes, Explain below)

Yes

No

Blood Thinners History:

Allergic Reactions:

List all medical allergies and reaction.

Medical Conditions:

Please check box for any of these medical conditions you have or have a history of, then fill out box below with the date of diagnosis, treatments received and other necessary information.

PLEASE TAKE YOUR TIME TO REVIEW THE FOLLOWING:

If yes to any of these medical conditions listed or any other medical condition, please explain the date of diagnosis and treatment received:

Surgical History:

Ever had Bariatric Surgery?

If Previous Bariatric Surgery, please explain:

Have you had any previous surgeries?

Yes

No

If yes to previous surgeries, please list operation type and year

Complications from Any Surgery?

Yes

No

Complications From Surgery:

Ever have any problems with Anesthesia?

Yes

No

Anesthesia problems:

Gynecologic History (women only)

Are you Pregnant or is there a Possibility of Becoming Pregnant?

Yes

No

Stats

Current Weight

Most You Have Ever Weighed

Height - Feet*

Inches*

Personal Info

Date of Birth

First Name

Last Name

Phone

Email*

Do you agree the statements you've made to me are accurate and if you fail to tell the truth, there can be serious consequences including, but not limited complications and may incur additional fees or cancelation.

Honesty and Truth:

Yes, I agree with above:*

No.

Patient Coordinator

Ann

Jasmine

Marisa