Have you received any treatment with us before?* YesNo

    Birth Date*

    Do you take any medications/drugs?* YesNo

    Do you take, or have you take in the past Blood-thinners?* YesNo

    Penicillin* YesNo

    Sulfa Drugs* YesNo

    Iodine* YesNo

    Tape* YesNo

    Latex* YesNo

    Aspirin* YesNo

    High lipid levels* YesNo

    Previous Bariatric Surgery*

    Date of surgery*

    Have you ever had a problem with an anesthetic?* YesNo

    Do you smoke cigarettes?* YesNo

    Do you drink alcohol?* YesNo

    Use recreational drugs?* YesNo

    Are you easy fatigued?* YesNo

    Do you have shortness of breath?* YesNo

    Do you have asthma?* YesNo

    Stroke* YesNo

    Diabetes* YesNo

    Coronary Artery Disease* YesNo

    Liver disease* YesNo

    Lung disease* YesNo

    Renal disease* YesNo

    Thyroid disease* YesNo

    Hypertension* YesNo

    Any other illnesses* YesNo

    Date of last menstrual period*

    Do you use any type of birth control?* YesNo

    Birth Control*

    Are you presently, or have you ever taken hormones?* YesNo

    Are you presently, or is there a possibility of you being pregnant?* YesNo

    Have you had any previous surgery?* YesNo

    Previous Surgery

    Do you use or B-PAP while your sleep?* YesNo

    Do you exercise?* YesNo


    When are you planning on having surgery?*

    Photographs: Completely Naked so doctors can have a clear view of surgical areas for evaluation.



    Left side*

    Right side*


    • For your evaluation this info must be submitted. The surgeons will evaluate your case based on a overall individualized cased. Surgical plan can be changed upon consult face to face evaluation.