Información de Contacto

Nombre:
Correo (requerido)

Celular
Género MaleFemale
Ocupación
Fecha de Nacimiento

Peso actual

Peso:
Altura:
BMI:

Preferencias de la Cirugía:

¿Que procedimiento estas interesado?Manga GástricaManga Gástrica de Una incisiónBypass GástricoMini Bypass GástricoBalón IntragástricoSwitch DuodenalSADI-SRevision (Lap Band to Gastric SleeveRevision (Lap Band to Gastric Bypass)Revision (Lap Band to Mini Gastric Bypass)Revision (Gastric Sleeve to Gastric Bypass)Revision (Gastric Sleeve to Duodenal Switch)Revision Gastric Sleeve to Mini Gastric Bypass)Revision (Gastric Bypass to Gastric Bypass)
Fecha del Procedimiento:
Cirujano de preferencia: Dr. Alberto CarlosDra. Mónica Valencia

Historial de Salud

Enfermedades

Have you ever been diagnosed with Hepatitis?:
YesNo
Have you ever been diagnosed with HIV?:YesNo
¿Has sido diagnosticado con SIDA?YesNo
¿Alguna vez te han diagnosticado una hernia de hiato? YesNo
¿Tienes alergias? YesNo
¿Que tipo de Alergias? (Desarrolla)[/group]
¿Tienes Diabates tipo I? YesNo
¿Tienes Diabates tipo II? YesNo
¿Te han diagnosticado diabetes pregestacional? YesNo

¿Sufres de alguna enfermedad del corazón? YesNo
Por favor explique:Please Explain: [/group]

¿Tienes asma? YesNo
[group asthma-treatment]Please Explain: [/group]

¿Sufre de presión alta? YesNo
[group high_blood_pressure]Please Explain: [/group]

Do you have any kidney or urinary disorder? YesNo
[group kidney-disorder]Please Explain: [/group]

Do you suffer from any neurological condition? YesNo
[group neuro-disorder]Please Explain: [/group]

Have you been diagnosed with Gallstones? YesNo
[group gallstonesgr]Please Explain: [/group]

Have you been diagnosed from any nervous or psychological disorder? YesNo
[group psychogr]Please Explain: [/group]

Have you had any gastric or duodenal ulcer? YesNo
[group ulcergr]
Please Explain:
[/group]

Have you had any liver disorder? YesNo
[group livergr]
Please Explain:
[/group]

Do you currently have anemia or any Blood imbalance? YesNo
[group anemiagr]
Please Explain:
[/group]

Do you suffer from heartburn or reflux? YesNo
[group refluxgr]
Please Explain:
[/group]

Was your gallbladder ever removed? YesNo

Are you receiving kidney dialysis treatments? YesNo

Do you have any additional medical condition to report to the surgeon?
YesNo
[group Illnessgr]Disease:
Diagnosed Date:
Treatment:
Outcome:
[/group]

Medications & Lifestyle

Do you drink alcoholic beverages?: YesNo
[group alcoholicgr]How often: [/group]
Do you Smoke? YesNo
[group smoke-text]How often: [/group]

Do you use any recreational drugs? YesNo
[group drugs-text]How often: [/group]

List your current medications, reason and dosage:
¿Tomas algún anticoagulante? YesNo
¿Cual y en que dosis? Which and dosage: [/group]

Cirugías Previas

¿Tienes cirugías previas? YesNo

[group previous-surgeries]Procedimiento:
Fecha del Procedimiento:
Razón:
Tipo de ProcedimientoOpenLaparoscopic
[/group]

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