Where do you live?
United States
Canada
Mexico
Other
Native Language?
English
Spanish
Emergency contact
Have you ever had weight loss surgery in the past?
No
Yes
If yes, please tell us about this procedure
Have you seen a doctor in the past about weight loss surgery?
No
Yes
Have you ever had an abdominal surgery, endoscopy, or plastic surgery?
No
Yes
Have you undergone anesthesia in the past? (local, epidural or general)?
No
Yes
Have you been pregnant? How many times? Did you deliver via cesarean section (C-section)?
Do you have regular or irregular menstrual periods?
Regular
Irregular
Do you suffer from acid reflux?
No
Yes
Do you have gastritis?
No
Yes
Do you have high blood pressure?
No
Yes
Do you have diabetes?
No
Yes
Do you have high cholesterol?
No
Yes
Do you have sleep apnea?
No
Yes
Do you use a C-Pap or B-Pap machine
No
Yes
Do you currently, or have you ever suffered from depression?
No
Yes
If yes, are you currently under treatment?
No
Yes
Do you have a history of heart problems? (attack, angina, arrhythmia)
No
Yes
Do you have joint pain or joint injuries or conditions?
No
Yes
Do you have swelling in your legs, ankles, or have varicose veins?
No
Yes
Do you have asthma, Bronchitis, or Chronic Cough?
No
Yes
Do you suffer from thyroid problems?
No
Yes
Do you have Ulcerative Colitis or Crohns Disease?
No
Yes
Do you have problems with your liver or gallbladder, or pancreatitis?
No
Yes
Have you ever had cancer or tumors?
No
Yes
Please describe your typical diet:
