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

First Name*

Last Name*

Email*

Phone

Procedure*

Gender*

Male

Female

Weight*

Height*

Date of Birth*

Country*

Goals

Emergency Contact

First Name*

Last Name*

Phone*

Health Care Provider

Name

Time Period

Treatments

Comments

Allergies

Actual Medications

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

Name

Dosis/Frequency

Purpose

Time Period

Add record Remove record

Diseases

Please add as many records as you need

Disease

Date

Treatment

Outcome

Add record Remove record

Surgeries

Please add as many records as you need

Surgery

Date

Reason

Add record Remove record

Family Background

Please add as many records as you need

Family Member

Living

Yes

Age or Age at Death

Cause of Death

Complexity

Thin

Overweight

Obese

Several Obese

Morbily Obese

Medical Condition

Add record Remove record

Respiratory System

Do You Experience Difficulty Breathing?

Yes

Do You Have or Had Asthma?

Yes

Do You Exercise?

Never

Rarely

Every Once in a While

Sometimes

Almost Always

Circulatory System

Do You Experience Swelling in Your Ankles?

Yes

Endocrine System

Do You Have Thyroid Problems?

Yes

Do You Have Diabetes?

Yes

Do You Track Blood Glucose?

Yes

Have You Been Diagnosed with POS?

Yes

Cardiac System

Do You Have High Blood Pressure?

Yes

Do You Experience Chest Pains?

Yes

Do You Have a Clinical History for Heart Diseases?

Yes

Hepatic System

Have You Been Diagnosed With a Liver Disease?

Yes

Immune System

Do You Have Rheumatoid Arthritis?

Yes

Are You Taking NSAIDs for Joint Pain?

Yes

Have You Been Diagnosed with Lupus?

Yes

Have You Been Diagnosed with HIV?

Yes

Digestive System

Have You Been Diagnosed with Diverticulitis?

Yes

Do You Have an Ulcers Background?

Yes

Have You Been Diagnosed with Crohn's Disease?

Yes

Do You Suffer of Indigestion?

Yes

Digestive Problems

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

Name

Reaction

Add record Remove record

Have You Had an Abdominal Pain?

Yes

Do You Have Hemorrhoids Background?

Yes

Mental Health

Have You Been Diagnosed with an Eating Disorder?

Yes

Are You Satisfied with Life in General?

Yes

Do You Have Clinical Record of Depression?

Yes

Use of Tobacco and Alcohol

Have You Consumed Tobacco Products?

Yes

Have You Consumed Alcohol?

Yes

Have You Consumed Caffeine?

Yes

Bones Health

Please add as many records as you need

Location

Details

Treatment

Outcome

Add record Remove record

Diet Background

How Long Have You Been Overweight?

Have You Taken Diet Pills?

Yes

What Have You Done in Order to Lose Weight?

Which Exercise Program Have You Done?

Diet Programs That You Have Been Through

Please check all that apply

Diet

Medication

Pritkin Diet

Slim Fast

Low-Calorie-Diet

Subliminal Tapes

Physician Supervised Diet

High-Protein Diet

Weight Watchers

Herbal Life

Medifast

Living Well Lady

Topfast

Jerry Craig

Overeaters Anonymous

Numerous Book Diets

Virginia Mason Clinic

Mayo Clinic

Tops

Rader Institute

Hypnosis

Optifast

Air Force Diet

Diet Center

Self-Imposed Fasts

Cabrini Eating Disorder

How Much Weight Did You Lose?

How Fast Did You Gain The Weight Back?

Do You Eat a Lot of Snacks?

Yes

Are You a Massive Devourer?

Yes

Do You Eat A Lot of Candy?

Yes

Do You Eat Fast Food and Sodas Frequently?

Yes

Systems Checklist

Please check all that apply

Frequent or Severe Fatigue

Frequent or Severe Weakness

Fever, Chills or Nocturnal Sweats

Frequent or Severe Headaches

Traumatic Brain Injury

Hearing Problems

Earache

Nasal Congestion

Cronic Sinus Congestion

Frequent Nasal Hemorrhage

Dental Problems

Dentures

Mouth Sores

Wheezing

Cough

Mammary Tumors, Pain or Secretion

Heart Murmur

Hypertension

Chest Pains Due to Exercise

Chest Pains Due to Physical Activity

Any STD non Treated

Birth Control

Infertility

Anemia

Blood Transfusion Background

Tendency of Bleeding

Convulsions

Paralysis

Numbness

Loss of Memory

Depression

Anxiety

Changes of Humor

Sleep Problems

Drugs and Alcohol Abuse

Hives or Cronic Rash

Asthma

Hay Fever

About CER Hospital

CER Hospital is a leading medical facility in the heart of Tijuana, Mexico that specializes in Plastic Surgery and Bariatric Surgery. Our licensed surgeons have the experience and expertise to help you highlight your natural beauty.

Contact Info

info@hospitalcer.com

Diego Rivera 2386, Zona Rio 22010

Tijuana, Baja California, Mexico

Medical Directory

Privacy Notice

Contact Numbers

Hospital: +52-664-634-2960

Plastic Surgery: +1-619-616-7949

Toll Free: +1-888-244-0326

Bariatric Surgery: +1-619-771-7401

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Achieve Your Ideal Weight with Bariatric Surgery

Clinical History

Achieve Your Ideal Weight
with Bariatric Surgery

Clinical
History