Patient Eligibility Questionnaire PERSONAL INFORMATION Procedure —Por favor, elige una opción—Gastric SleeveGastric Sleeve (Single Incision)Gastric PlicationGastric BypassMini Gastric BypassGastric BandGastric Balloon (Orbera)Gastric Balloon (Orbera Removal)Gastric Balloon (Spatz3)Gastric Balloon (Spatz3 Adjustment)Gastric Balloon (Spatz3 Removal)Duodenal SwitchSleeve to Mini Gastric Bypass (Revision)Re-Sleeve (Revision)Band to Mini Gastric Bypass (Revision)Band to Sleeve (Revision)RE-Bypass (Revision)Bari-Clip Full Name Email Sex Age Height Weight BMI Date of Birth (dd/mm/yy) Telephone Address City State Zip OTHER INFORMATION Maximum Weight Date at Max Weight? (dd/mm/yy) Date Of Surgery (dd/mm/yy) List All Medecine Allergies Name of Person to Contact (In Case Of Emergency) Emergency Phone QUESTIONNAIRE Do you have any medical/physical problems (i.e., sleep apnea, high blood pressure, diabetes, high cholesterol, blood diseases, neurogical disorders, etc)? YesNo Please list 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? YesNo Please indicate which ones: Have you had any surgeries (i.e., galibladder, appendix, hernia, heart, etc.)? YesNo Please list Do you have any adverse reactions to anesthesia? YesNo Please indicate the reaction Do you have dentures, dental implants, or caps? YesNo Please indicate where Do you have any children? YesNo How many? Do you have heavy periods? YesNo Do you smoke? YesNo Do you drink? YesNo Do you do drugs? YesNo FOR THE FOLLOWING QUESTIONS, PLEASE INDICATE "YES" "NO" OR "DO NOT KNOW". Aspirin (Excedrin, Anacin, Bufferin) YesNoI don't know Anticoagulants (blood-thinning medicine) YesNoI don't know Propanol Verapamil (heart rhythm medicines) YesNoI don't know Diuretics (water pills) YesNoI don't know Antihypertensive Drugs (blood pressure pills) YesNoI don't know Digitalis (heart pills) YesNoI don't know Steroids (prednisone, cortisone) YesNoI don't know Have you ever been treated for cancer with chemotherapy or radiation therapy? YesNoI don't know Liver (e.g. cirrhosis, hepatitis, yellow jaundice) YesNoI don't know Kidneys (infection, stones, failure) YesNoI don't know Spleen YesNoI don't know Blood (anemia, leukemia) YesNoI don't know Have you or anyone in your family ever had a serious bleeding problem? YesNoI don't know Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed? YesNoI don't know Do your gums bleed when you brush your teeth? YesNoI don't know Are you pregnant? YesNoI don't know Is there a possibility that you are pregnant? YesNoI don't know Have you been told you have diabetes? YesNoI don't know Do you wake up to urinate more than once at night? YesNoI don't know Do you have muscle cramps or pains? YesNoI don't know Do you have problems with your lungs or chest? (e.g. chest pain, skipped heart beats, high blood pressure, smoke one or more packs a day, shortness of breath, emphysema, asthma, bronchitis) YesNoI don't know Please list Do you have a cough or flu frequently? YesNoI don't know Do you have epilepsy, or suffer from fits or seizures? YesNoI don't know Do you have neck or back problems? YesNoI don't know Are you scheduled to have an operation? YesNoI don't know Send
