Contact Information Name (required) Email (required) Phone (required) Gender MaleFemale Occupation Date of Birth Current Weight Weight: Height: BMI: Surgery Preferences Which Procedure are you interested in?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) Procedure Date: Prefered Surgeon: Dr. Alberto CarlosDra. Mónica Valencia Health History Diseases Have you ever been diagnosed with Hepatitis?: YesNo Have you ever been diagnosed with HIV?:YesNo Do you refuse blood transfusions?:YesNo Have you ever been diagnosed with Hiatal Hernia?: YesNo Do you have any allergies?: YesNo What type of Allergies? Do you have Type I Diabetes: YesNo Do you have Type II Diabetes: YesNo Have you been diagnosed with pregestational diabetes? YesNo Do you suffer from any Heart Disease? YesNo Please Explain: Do you have Asthma? YesNo Please Explain: Do you suffer from High Blood Pressure? YesNo Please Explain: Do you have any kidney or urinary disorder? YesNo Please Explain: Do you suffer from any neurological condition? YesNo Please Explain: Have you been diagnosed with Gallstones? YesNo Please Explain: Have you been diagnosed from any nervous or psychological disorder? YesNo Please Explain: Have you had any gastric or duodenal ulcer? YesNo Please Explain: Have you had any liver disorder? YesNo Please Explain: Do you currently have anemia or any Blood imbalance? YesNo Please Explain: Do you suffer from heartburn or reflux? YesNo Please Explain: 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 Disease: Diagnosed Date: Treatment: Outcome: Medications & Lifestyle Do you drink alcoholic beverages?: YesNo How often: Do you Smoke? YesNo How often: Do you use any recreational drugs? YesNo How often: List your current medications, reason and dosage: Do you take any blood thinner? YesNo Which and dosage: Previous Surgeries Do you have previous surgeries? YesNo Procedure: Procedure Date: Reason: Procedure Type:OpenLaparoscopic Δ
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