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Bariatric Form
First Name
Last Name
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ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST
ARMED FORCES AMERICA (EXCEPT CANADA)
ARMED FORCES PACIFIC
Did you have your Video Consultation
Did you have your Video Consultation?
Yes
No
Consultation Date
Consultation Time
Age
Gender
Select Gender
Male
Female
Weight
Height
BMI
Proposed Surgical Date
Date of Birth
Desired Medical Procedure
Do you Have a Passport?
Do you Have a Passport?
Yes
No
Occupation
Marital Status
Marital Status
Married
Divorced
Widowed
Next of Kin Name
Emergency Contact
Emergency Contact Telephone:
Does food ever get stuck?
Does food ever get stuck?
Yes
No
Any of this conditions?
Alcohol / Drugs
Allergies
Anemia or Bleeding Disorder
Asthma
Back Pain
Diabetes
Gallstones
Gastric or Duodenal Ulcer
Gastroparesis (contraindication for a sleeve)
Heart Disease
Hepatitis or Liver Disease
High Blood Pressure
Kidney or Urinary Disorder
Reflux or Heartburn
Sleep Apnea
Smoking
Thrombosis or Clotting Disorder
Thyroid Issues
Name Drugs / Allergies Here
Please List your medications and dosages here
Do you have any questions or suggestions for Dr A?
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