Interested in

Gastric Sleeve

Adjustable Lap-Band

Intragastric Ballon - Orbera

Instragastric Ballon - Spatz 3

Mini Gastric Bypass

Gastric Bypass

General Surgery

Are you allergic to any medication?

If Yes, Please Specify

Have had any previous weight loss procedures?

If Yes, Please Specify

Have had any previous open abdominal surgery?

No

C-Section

Appendix

Gallbladder

Hiatal Hernia

Other

Please Specify

Intake of Heart Medications

Yes

No

Aspirin

Other

Please Specify

Do you have any heart conditions?

No

Arrytimia

Cardiac Arrest

Clotting Disorder

Congenital Heart Disease

Congestive Heart Failure

Coronary Artery Disease

Heart Attack

Heart Valve Disease

Peripheral Artery Disease

Stroke

Other

Please Specify

Do you have digestive disorders?

No

Heartburn - Gerd

Gastritis

Colitis

Crohn´s Disease

Diverticulitis

Ulcerative Colitis

Inflamatory Bowel Disease

Irritable Bowerl Syndrome

Other

Please Specify