Affordable Weight Loss Surgery in Mexico & Henderson, NV | Bariatric Surgery, Plastic Surgery, & More | Bariatric Surgery Solutions
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Home» Eligibility

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:

    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:

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