Achieve Your Ideal Weight
with Bariatric Surgery

Clinical
History

Find out if you are a candidate for surgery. To help our team of bariatric surgery professionals best understand your needs as a bariatric surgery patient, we request that you complete our clinical history form.

Please fill in the following register to complete your clinical history, it will take you approximately 10 minutes to fill it out, once you have submitted your form, the doctor will review your file and we will contact you in an estimated 48 hours.

Please enter the required data.

Personal Info

Emergency Contact

Health Care Provider

Allergies

Actual Medications

Please add as many records as you need, include vitamins, herbal supplements, orver-the counter medication, etc

Diseases

Please add as many records as you need

Surgeries

Please add as many records as you need

Family Background

Please add as many records as you need

Respiratory System

Circulatory System

Endocrine System

Cardiac System

Hepatic System

Immune System

Digestive System

Digestive Problems

Food and beverages that causes digestive problems, please add as many records as you need

Mental Health

Use of Tobacco and Alcohol

Bones Health

Please add as many records as you need

Diet Background

Diet Programs That You Have Been Through

Please check all that apply

Systems Checklist

Please check all that apply