Medical Questionnaire













   
Weight Loss History - It is critical that you fill this out in detail -
How tall are you?
How much do you currently weigh?
   
REVIEW OF MEDICAL PROBLEMS - (Please answer and explain any of the items listed)

   
DIABETES AND ENDOCRINE SYSTEM


   
GASTROINTESTINAL
   
If Yes When? Findings?

   
RESPIRATORY

   
Number of times in past 2 years? - Is it recurring?
   
Smoking history









   
Sleep apnea history
If you answered NO to the above, answer the following questions
   
Do you still feel exhausted after 8 hours of sleep?
   
If you answered YES to more than four of the above questions, you may have Sleep Apnea and either you should talk to your doctor about a sleep study, or we will make arrangements for one to be done. This study is painless and can significantly help improve the safety of the operation. If you have had a sleep study performed in the past 6 months, please fax, mail or bring a copy of the results to our office.
   
MUSCULOSKELETAL



   
KIDNEY & BLADDER
   
BLOOD
   
FOR WOMEN
   
NEURO-PSYCHIATRIC
   
PAST SURGICAL HISTORY

   
MEDICATIONS






   
FAMILY HISTORY
  Mother Father Sibling Aunt/Uncle Grandparents
Obesity
Diabetes
Heart Disease
High Blood Pressure
Cancer
Arthritis
- Cause
Early Death

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Information All information provided by me is true and accurate.
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