Formulario Cirugía Bariátrica - Lefny Plastic Surgery

How did you find out about us?

What procedure do you want to undergo?

Where do you want to have your surgery?

Dominican Republic

Write 3 possible dates for your surgery

Have you been diagnosed with any of these digestive conditions?

Have you had any of these major surgeries or medical procedures?

Perforated appendicitis Cesarean sections (3 or more) Laparotomy Recent abdominal or pelvic surgery (less than 1 year) Accidents or injuries affecting the digestive system Inflammatory gastrointestinal diseases None of the above

Do you have or have you had any of these medical conditions related to the digestive system?

Do you commit to following the medical treatment regimen recommended within the program?

Yeah No

Do you do physical activity regularly?

Yeah No

How often do you do physical activity?

Occasionally (once a week or less) Moderate (2-3 times per week) Frequent (4-5 times a week) Diary

Type of physical activity

Cardiovascular (running, walking, cycling, swimming) Strength training (weights, calisthenics, gym machines) Functional exercise (yoga, pilates, circuit training) Sports (football, tennis, basketball, etc.)

Do you smoke? Please indicate how often

Never Occasionally Frequently Diary

Do you drink alcohol? Please indicate how often

Never Occasionally Frequently Diary

Drugs? Please indicate how often

Never Occasionally Frequently Diary

Do you have any children?

Yeah No

Caesarean sections?

Yeah No

Have you been diagnosed with an eating disorder?

Yeah No

Specify the associated diagnosis or disorder

What do you consider to be the main cause of your overweight?

How many full meals do you eat a day?

Between 1-2 3 4 or more Varies depending on the day

Do you have any illnesses?

Yeah No

What diseases do you have?

Are you taking medication?

Yeah No

What medications are you taking?

Are you taking any supplements or fat burners?

Yeah No

What supplements or fat burners are you taking?

Have you had any surgery?

Yeah No

What surgery have you had?

Do you have any allergies?

Yeah No

What allergy do you have?

Are you HIV POSITIVE?

Yeah No

Do you have Lupus?

Yeah No

Do you have Hepatitis B or C?

Yeah No

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