First Name
E-Mail
OBESITY MEDICAL HISTORY QUESTIONNAIRE
Address
Last Name
City
State
Zip
Country
Phone # (if none, put none)
Date of Birth
Procedure(s) Requested
Height
Gender
Weight
Do you smoke?
Current medications and supplements
Please Check all that Apply:
Addiction to alcohol or drugs
Arthritis
Asthma/Breathing Problems
Autoimmune
Bleeding Problems / Blood Clots
Blood Disorders
Cancer
Cardiac Arrhythmia (rapid heart rate)
Chronic Pancreatitis
Cirrhosis of the Liver
Exposure to Tuberculosis
Gallstones
Gastro Issues (Crohn's, Ulcerative Colitis, etc.)
GERD (acid reflux)
Heart Murmur
Hepatitis
Heart or Vascular disease
High Blood Pressure, Coronary Artery Disease or Circulatory conditions
HIV or AIDS
Hypertension/ High Blood Pressure
Kidney Disease
Metabolic Conditions. (i.e. hypothyroidism)
Previous reactions to Anesthesia Clots
Seizures or Epilepsy
Sleep Apnea
Stroke
Thromboembolism
Type 2 Diabetes
Do you have any medical condition that you have been told would disqualify you for any type of medical procedure or surgery?
Do you need special accommodation? (dietary, sensory, handicap, etc)
Do you have any other medical condition that you are aware of that is not listed above?
If you checked or said yes to any above, please explain
Your Medical Provider
Provider Contact #
Do we have permission to contact?
Please list all previous surgeries or hospitalizations
Please list all allergies
How did you hear about us?
Chronic, Long term Steriods (past or present)
How long have you been overweight?
What programs/diets have you tried?
Upload an attachment / picture
Agreement: By clicking the Submit button, I certify that I have read, understand and agree to the Privacy Policy and Terms of Use posted on this website. I have the right to submit the above information and agree that it is accurate to the best of my knowledge and that skyMedicus and its affiliates are authorized to use it in any way on my behalf to secure health services. I further understand that electronic copy of this Authorization is as equally valid as any original signature or document.
Terms of Service | Privacy Policy | Media | About Us | Contact Us