Questionnaire for Bariatric Surgery

1.

In order for the surgeon to make the correct choices regarding the surgery type for the patient, please fill out this form. It is important that the surgeon has all the necessary data about the patient to mitigate the risk of surgery and to provide the best possible results for the patient.

The data collected and information provided is strictly confidential and will only be reviewed by the patient co-ordinator, anaesthesiologist and the surgeon. It will take about 10-15 minutes to complete this questionnaire.

Question Title

* 1. Contact information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Sex

Question Title

* 3. Birth date

Question Title

* 4. Height

Question Title

* 5. Current weight

Question Title

* 6. Maximum weight

Question Title

* 7. Weight unit

Question Title

* 8. Emergency contact

Name

Phone no

Question Title

* 9. Primary care doctor (GP)

Name

Phone no

E-mail address

Address