Medical Information
 (*Required Fields)
*Name: *Home Address:
*City, State:
*Country:
Area Code :
*Phone:
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Occupation:
In Case of Emergency Please Notify
*Name: Phone:
Who has referred you to our office?: 
A doctor: Another patient:
Publishing advertisement: Other:
What kind of procedure are you interested on?
* How old are you?  
 
Medical Information
Please fill out this medical questionnaire to the best of your knowledge. It will help us make better decision regarding your surgical procedure.
(Yes)   (No) (Yes)    (No)
*Do you have any heart problems?      *Do you have alcohol problems?     
*Do you suffer from asthma?      *Do you have high blood pressure?     
*Do you have coagulation disorders?      *Do you have an ulcer?     
*Do you have diabetes?      *Do you smoke?     
*Do you have heartburn?         
*List any medications you take regularly: Please list your known allergies: List the major, if any, surgeries you have had: 
*Did you have abnormal bleeding after any of them? (Yes) (No)
Is there any other medical issue that we have not asked you about?

 

Phone: (506)2208-1515 • Fax: (506)2208-1535 • Beeper: (506)2225-2525
5th Floor medical Tower CIMA San Jose Hospital

E-mail: info@bariatricscr.com

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For more information about Bariatrics and Minimally Invasive Surgery please e-Mail us to: info@bariatricscr.com | Tel. (506) 2208-1515 | © Bariatrics and Minimally Invasive Surgery. All rights are reserved.