Eligibility Questionnaire

The information submitted by you is privileged and confidential, Obesity Goodbye does not distribute or sell this information to 3rd parties, as it is used strictly for internal purposes.

Personal Information

Patient facilitator name:

Procedure*

Date*

First Name*

Last Name*

Email*

Phone*

Cell

Emergency Phone*

Contact name in case of emergency*

Address*


Street Address


City


State / Province / Region


ZIP / Postal Code


Country

Medic Information


Date of birth*

Age*

Por favor, introduzca un valor entre 5 y 90.

Height*

0 de 5 caracteres máximo

Weight*

0 de 5 caracteres máximo

BMI*

0 de 10 caracteres máximo

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?*
YESNO

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?*
YESNODO NOT KNOW

If yes, what kind & how often?