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                   Affordable Weight Loss Surgeries       

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Patient History


PATIENT HISTORY FORM

Thank you for selecting our services.
Please feel free to contact our office with any questions you may have.

Name: *

Today's Date:

Phone # *

Cellphone #

Address: *

E-mail: *

Weight: *

Height: *

BMI: *

Age: *

Date of Birth: * 

Surgical Date:

Surgeon:

Procedure(s):

Person traveling with you:  Relationship:

 

Please check the following conditions that apply to you: 

Anemia

Pregnant

Heart disease

Seasonal allergies

Asthma

Indigestion

Ankle swelling

Painful urination

Cancer

Constipation

Tuberculosis

Difficult urination

Headaches

Diarrhea

Sleep apnea

Shortness of breath

Diabetes 1

Acid reflux

Bruise easily

Confusion / Depression

Diabetes 2

Glacoma

Hypertension

Difficulty swallowing

Epilepsy

Convulsions

Freq. nausea

Gall Bladder problems

Ulcers

Paralysis

Liver problems

Mental Disorder / Bi-Polar

Vomiting

Pneumonia

Low back pain

Unusual lumps, bumps or masses

Chest Pain

Sore throat

C-pap machine

Lung problems / congestion

Please explain about your previous medical conditions ( if selected above ).
Tobacco use: 

None    Minimal    Moderate    Heavy
Drug use: 

None    Minimal    Moderate    Heavy    
Alcohol use: 

None    Minimal    Moderate    Heavy        

Current medications:

Medication, Usage, Dosage, How often?

 

Previous surgeries and hospitalizations:
Latex allergy: 

YES   NO
Drug allergies:

Food allergies:

THE PERSON LISTED BELOW WILL BE YOUR HOME CONTACT PERSON.  
WE WILL NOT RELEASE ANY INFORMATION TO ANYONE WHO IS NOT LISTED. 

AGREE:        YES    NO

Please contact:  after my surgery at:

IN CASE OF EMERGENCY* 

Please list the person(s) name, phone number and relationship to you:

Please list any health issues that were not addressed in the medical information above:

Procedure quote:    $

Deposit paid:    $ 

Type of payment for the remaining balance:
Note for Canadian patients: Travelers checks or wire transfers ONLY
Items Not Covered:

Additional hospital expenses if the patient has to stay in the hospital for a longer time. Expenses due to complications. Doctor's fees for appointments, before and after the surgery. Additional prescriptions, special studies or tests ARE NOT COVERED.
Please initial if you agree: *    

PLEASE NOTE: There are no refunds for any type of surgery after surgery is performed, or expenses you
have or may incur.
Please initial if you agree: * 

Sign with your initials if all is true: *    

Are you a candidate?
 

An ideal BMI is between 19 and 25.
A BMI between 26 and 29 is considered overweight. If it is over 30, one is considered obese and at risk for serious health problems. A BMI of 35 or more is considered severely or morbidly obese.

You may be a candidate for surgery if:

  • Your BMI is 30 or higher.
  • You have severe sleep apnea, diabetes or heart problems
  • You've been overweight for more than 5 years
  • You're unable to sustain weight loss from diet attempts.
  • You are willing to change your lifestyle and eating habits
  • You DO NOT drink alcohol to excess.

Privacy Policy

The information submitted by you is privileged and confidential.

Successfully Slimmer LLC,  does not distribute or sell this information to 3rd parties, as it is used strictly for internal purposes.

Successfully Slimmer, LLC is a coordinating/scheduling service and not a healthcare provider. The included information does not constitute medical advice or expertise. 
Successfully Slimmer, LLC shall not be liable for any decision made in reference to this information.

Content copyright . Successfully Slimmer, LLC. All rights reserved.


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