Bariatric Questionnaire – Body Says Tijuana

BASIC INFORMATION

First Name

Last name

Phone number

Best way to contact you

Best time and day to reach you

Date of birth

How did you hear about Body Says Bariatrics

How soon do you plan to have surgery

What key concern is delaying your decision to proceed with surgery

MAILING ADDRESS

Street name and number

Phone number

City

State

Country

Zip Code

Emergency contact name

Emergency contact phone number

HEALTH INFORMATION

Height in feet and inches

Weight in pounds

Age

Gender

Male Female Prefer not to say

Have you ever had surgery before

Yes No

If yes, which one

Are you currently taking any prescription medication

Yes No

If yes, which one

How would you describe your overall physical condition

Are you able to walk upstairs without assistance

Yes No

Are you able to walk short distances without assistance

Yes No

Do you currently smoke or vape

Yes No

Do you drink alcohol

Yes No

Do you use any recreational drugs

Yes No

TERMS AND CONDITIONS

All information that you are required to provide with this Health Questionnaire, as well as any other medical information, thereafter, is required to be truthful, complete, and accurate. If it not accurate, the surgeon can cancel your surgery resulting in the lost of security deposit and all money paid already for the surgery.
It is imperative that the height and weight reported on the Health Questionnaire be accurate. All patients upon admission, their weight and height will be taken prior to their surgery. If the BMI (Body Mass Index) at the time of the surgery does not accurately reflect the height and weight reported on the Health Questionnaire, the surgeon can make the decision to cancel the surgical procedure, thus denying the refund of any monetary deposit.
If you decide to schedule your surgery, we reserve the right to be able to contact you via phone, email and/or text message.

I agree to the terms and conditions

Plastic Surgery

Bariatric Surgery

Plastic Surgery

Bariatric Surgery

Medical Questionnaire

Baja Integrative Health Center Antonio Caso 2055, Zona Urbana Rio Tijuana, 22010 Tijuana, B.C.

bajacentertijuana@gmail.com

+1 (619) 779-4005

Plastic Surgery

Bariatric Surgery