1.- PERSONAL DATA

Name:

Address

City

State

Zip Telephone: Area Code

Number Email address:

General data

Date of Birth: Age

Occupation: Sex: Male Female

Weight (lb.) Height (ft. in.)

Familiar Incidents of Obesity

Parents

Brothers

2.- MEDICAL DATA

* * Please check as many of the options
that apply to you,  and provide your comments
 in the other remarks box below * *

CARDIOVASCULARES

High Blood Pressure
Heart Attack
Stroke
Heart Failure
Chest Pain when walking
Varicose Veins
Phlebitis Pulmonary Embolus

RESPIRATORY

Phlebitis Pulmonary Embolus
Asthma
Sleep Apnea

GYNECOLOGICAL

Pregnancies
Premenstrual Bleeding

Menstrual History: Regular Irregular

GASTROINTESTINAL

Hiatus Hernia and/or heartburn
Stomach Ulcers
Gallstones
Chronic Constipation
Blood with Bowel Mover
Previous Surgery

ENDOCRINE

Thyroid
Diabetes
High Cholesterol
Other Endocrine

PSYCHO/SOCIAL

Eating Disorders
Consultation or Therapy

OTHER DIASES

Neurological
Urinary

MUSCULO-SKELETAL

Joint Pain

Hips
Knees
Ankles
Lower back

Arthrosis

Hips
Knees
Ankles
Lower Back

DRUGS

Diet Pills
Substances Abuse
Smoking
Alcoholic Drinks per day

MEDICATIONS

Prescribed

Self Administered

ALERGIES

Aliments

Medicine

DIETS

Previous diets you have followed

When

Weight Lost Lb.

Weight Regained Lb.

3.-  COMMENTS

Your timeframe of Adjustable Gastric Band ?  

Intermediately

3 – 6 Months

6 – 9 Months

HOW DID YOU KNOW ABOUT US?

Internet
Press or Media
Personal References
Other Which?

Other Remarks