Personal Information
Name*
Cell Phone*
Email*
How did you hear about us?*
Street Address
Address Line 2
City
State/Region/Province
Postal/Zip Code
Country
-Select- Åland Islands Afghanistan Akrotiri Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Islands Australia Austria Azerbaijan Bahrain Bangladesh Barbados Bassas Da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Coral Sea Islands Costa Rica Cote D'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Dhekelia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Juan De Nova Island Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich
Islands South Korea South Sudan Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wake Island Wallis and Futuna West Bank Western Sahara Yemen Zambia Zimbabwe
Date of Birth
Age*
Sex*
Height: Feet*
Height: Inches*
Weight (lbs)*
BMI
Emergency Contact Info
First Name*
Last Name*
Email*
Cell Phone*
Surgery of Interest
What procedure are you interested
in?*
-Select- Gastric Sleeve Gastric Bypass Mini Gastric Bypass Revision Surgery Plastic Surgery Other
Are you interested in a particular bariatric surgeon?
-Select- Doctor Francisco Gonzalez Doctor Mario Camelo Doctor Juan Pedro Fernandez I don't know yet
Have you had previous bariatric surgery?
If your answer is yes, please answer the following
questions
Describe which one
Was your past procedure
When was your bariatric
procedure?
Family History Medical History Tell us a bit more about your past medical history. This will help our medical staff create a
better medical profile.
Did you have Covid-19?
If Yes, how severe?
Please describe the symptoms you had. If you were hospitalized or intubated.
Are you allergic to any medication?
If your answer is yes, please answer the following
questions
Please list any allergies that you have
Have you had any anaphylactic shock or endotoxic shock?
How many times you had those anaphylactic shocks or endotoxic shocks?
Please include dates, too.
Type of Blood
-Select- O negative O positive A negative A positive B negative B positive AB negative AB positive
Medications currently taking
Please list all medications that you are currently taking, over the counter medications, herbal, vitamins, supplements etc.
Are you taking blood thinners?
If your answer is yes, please answer the following
question
What kind of blood
thinners are you taking? (Ex., aspirin, NSAID's, ibuprofen, ketorolac, naproxen,
ephedrine)
If your answer is yes, YOU SHOULD stop taking them 15 days before the
surgery to avoid any complications. >
Have you been diagnosed with heart disease?
If your answer is yes, please answer the following
questions
Date of diagnosis
Please tell us when you where diagnosed with heart disease
Describe your
treatment
If you have any study referred to your heart disease condition, please make sure
to send it in advance.
Have you been diagnosed with diabetes?
If your answer is yes, please answer the following
questions
Describe your treatment
Please let us know what kind of treatment do you use, if you are
insulin dependent, if you take pills, what kind of diabetes do you have
Have you been diagnosed with thyroid disorder?
If your answer is yes, please answer the following
questions
Describe your
treatment
Please let us know what kind of treatment do you use, if you take
pills, what kind of thyroid you have
Have you been dyslipidemia?
If your answer is yes, please answer the following
questions
Describe your
treatment
If you have any study referred to your dyslipidemia, please make sure
to send it in advance.
Have you been diagnosed with heart attack?
If your answer is yes, please answer the following
questions
Describe your
treatment
If you have any study referred to your heart disease condition,
please make sure to send it in advance.
Have you been diagnosed with high blood pressure?
If your answer is yes, please answer the following
questions
Describe your
treatment
Please let us know what kind of treatment do you use, doses taken
etc.
Have you been diagnosed with any lung disease? (COPD)
If your answer is yes, please answer the following
questions
Describe your
treatment
Please describe your condition.
Have you been diagnosed with any of the following?
List all serious illnesses that you have
had:
List all the surgeries that you have had:
Do you use CPAP machine?
Do you have sleep apnea?
Do you snore?
Gynecological History Only for women
Age First Menstruation
Last Menstruation
Number of Pregnancies
Number of Births
Number of C-Sections
Number of Abortions
Birth Control Method
History
Create a timeline with dates about your gynecological history. Example:
2007 - Birth. 2008 Abortion. 2009 Start using birth control
Social History Alcohol
Smoking
Drugs
If answer is not "Never", what kind of
drugs?
When would you like to get your surgery
done?
Necessary Documentation
It is very important to bring a valid ID to travel. If you do not have a passport, you can travel with your birth certificate and driver's license. In case a minor it is going to have a surgery, please bring a valid ID, too. (school ID, birth certificate or passport).
If you do not bring a valid ID, the surgery will not be performed.
I accept the Terms and Conditions.*
Terms and Conditions
I authorize Oasis of Hope Hospital and/or his designee to request medical information, if required, from
any of the physicians that have listed above, as a part of this health history questionnaire. The
information that is to be requested from the physicians may include but is not limited to, history and
physical exams, discharge summaries, consultation reports, laboratory and image studies.
I accept the Terms and
Conditions.*
I certify that my health history information is true and correct and that I am not intentionally
falsifying my health information or misleading in any way about my current health including intentionally
leaving out health information. I further understand that any false statements regarding my medical
history could result in cancellation of surgery and I would be responsible for all cost incurred by.
I
agree.*
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