Medical History - Dr Sergio del Hoyo | Especialista en Cirugía Bariátrica

Full name

Phone

Sex

Address

Weight

Height

BMI

You smoke?

You drink alcohol?

Have you had any weight loss surgery before?

Have you visited any weight loss surgeon?

Do you have any illness?

Do you take any medications, yes, no, which ones?

Have you had any abdominal surgery, endoscopy, plastic surgery?

Have you had any type of anesthesia, including local anesthesia for teeth?

Have you ever been pregnant?

Are your menstrual periods normal?

Do you have sleep apnea? Yes or no

Do you have problems with joints, back pain, knees? Yes or no

Do you have gastritis or reflux? YES or NO Describe how often and with what foods

Do you have hypertension or diabetes? Yes or No What medications do you take and how long have you known the disease?

Do you have high cholesterol? Yes or No Take any treatment

Do you have any allergies to foods or medications? Yes, which one is it

Do you have heart problems, arrhythmias? Yes or no

Do you have depression or anxiety problems? Yes or no, do you have any treatment?

Do you have lung problems such as asthma, bronchitis, pneumonia? Yes or no, do you have any treatment?

Do you have thyroid problems? Yes or no, do you have any treatment?

Do you have or have you had any type of tumor? Yes or no, what type of tumor have you had?

Do you have abdominal problems such as constipation, gallbladder problems? Yes or no, what problems have you had?

Describe your diet, the foods or eating habits that you consider to be a factor in your overweight problem.

Do you have any preferred surgery?

When do you want to schedule your surgery?

How many kilos would you like to lose with surgery?