Medical History Form

The information you provide will help us plan your treatment.
Please complete as much of this form as possible.

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

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?*

If you selected Other, please answer the following question

Other procedure are you interested in?

Are you interested in a particular bariatric surgeon?

Have you had previous bariatric surgery?

Yes

If your answer is yes, please answer the following questions

Describe which one

Was your past procedure

Open

Laparoscopic

When was your bariatric procedure?

Family History

Diseases and Conditions

List all of them here

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?

Yes

If Yes, how severe?

Please describe the symptoms you had. If you were hospitalized or intubated.

Are you allergic to any medication?

Yes

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?

Yes

How many times you had those anaphylactic shocks or endotoxic shocks?

Please include dates, too.

Type of Blood

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?

Yes

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?

Yes

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?

Yes

If your answer is yes, please answer the following questions

Date of diagnosis

Please tell us when you where diagnosed with diabetes

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?

Yes

If your answer is yes, please answer the following questions

Date of diagnosis

Please tell us when you had the thyroid disorder

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?

Yes

If your answer is yes, please answer the following questions

Date of diagnosis

Please tell us when you had dyslipidemia

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?

Yes

If your answer is yes, please answer the following questions

Date of diagnosis

Please tell us when you had the heart attacks

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?

Yes

If your answer is yes, please answer the following questions

Date of diagnosis

Please tell us when you where diagnosed with high blood pressure.

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)

Yes

If your answer is yes, please answer the following questions

Date of diagnosis

Please tell us when you where diagnosed with lung disease.

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?

Yes

Do you have sleep apnea?

Yes

Do you snore?

Yes

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

Almost Always

Sometimes

Once in a while

Rarely

Never

Smoking

Almost Always

Sometimes

Once in a while

Rarely

Never

Drugs

Almost Always

Sometimes

Once in a while

Rarely

Never

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.*