Eligibility Eligibility Questionnaire The information submitted by you is privileged and confidential. Bariatric Surgery Solutions does not distribute or sell this information to 3rd parties, as it is used strictly for internal purposes. Procedure:ChooseLap BandGastric SleeveGastric BypassFill Patient facilitator name: Date of surgery: *Name: *E-mail: *Telephones: *Home: Cell: *Emergency: *Contact name in case of emergency *Address: *City, State, Zip code: Date of Birth:: *Age: *Height: *Weight: BMI: Maximum Weight: When?: *List all Medicine Allergies: Any Medical/physical problems (i.e., sleep apnea, high blood pressure, diabetes, high cholesterol, blood diseases, neurological disorders, etc)? YesNoDo Not Know If Yes, please list: Are you currently taking any medications or herbal supplements? YesNoDo Not Know 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? YesNoDo Not Know If Yes, please indicate which ones: Any surgeries (i.e., gallbladder, appendix, hernia, heart, etc.)? YesNoDo Not Know If Yes, please list: Do you have any adverse reaction to anesthesia? YesNoDo Not Know If Yes, please indicate the reaction: Do you have dentures, dental implants, or caps? YesNoDo Not Know If Yes, please indicate where: Do you have any children? YesNoDo Not Know If so, how many? Do you have heavy periods? YesNo Do you smoke? YesNo If yes how many cigarettes a day? Do you drink? YesNo If yes , how many? Do you do drugs? YesNo If yes, what kind & how often? Pre-Operative Assessment Patient Name Age Sex Date For the Following Questions, Please Indicate "Yes" "No" or "Do Not Know". Please answer all of the questions. Do you currently take any of the following medications? a) Aspirin (excedrin, anacin, bufferin) YesNoDo Not Know b) Anticoagulants (blood-thinning medicine) YesNoDo Not Know c) Propanol, Verapamil (heart rhythm medicines) YesNoDo Not Know d) Diuretics (water pills) YesNoDo Not Know e) Antihypertensive drugs (blood pressure pills) YesNoDo Not Know f) Digitalis (heart pills) YesNoDo Not Know g) Stereoids (prednisone, cortisone) YesNoDo Not Know Have you ever been treated for cancer with chemotherapy or radiation therapy? YesNoDo Not Know If yes: when? Do you currently have any problems with your: a) Liver (e.g. cirrhosis, hepatitis, yellow jaundice) YesNoDo Not Know b) Kidneys (infection, stones, failure) YesNoDo Not Know c) Spleen YesNoDo Not Know d) Blood (anemia, leukemia) YesNoDo Not Know Have you or anyone in your family ever had a serious bleeding problem? YesNoDo Not Know Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed? YesNoDo Not Know Do your gums bleed when you brush your teeth? YesNoDo Not Know Are you pregnant? YesNoDo Not Know Is there any possibility that you are pregnant? YesNoDo Not Know Have been told you have diabetes? YesNoDo Not Know Do you wake up to urinate more than once at night? YesNoDo Not Know Do you have muscle cramps or pains? YesNoDo Not Know Do you have problems with your lungs or chest? (e.g., chest pain, skipped heart beats, high blood pressure, shortness of breath, emphysema, asthma, bronchitis) YesNoDo Not Know if yes please list: Do you have a cough, or cough frequently? YesNoDo Not Know Do you have epilepsy or suffer from fits or seizures? YesNoDo Not Know Do you have neck or back problems? YesNoDo Not Know Are you scheduled to have an operation? YesNoDo Not Know If Yes, what operation? Are you currently taking any medications? YesNoDo Not Know If Yes, please list:
