Medical History Patient IdentificationNombre *Last Name *Email Address *Tipo Cirugia *Surgery type*Bariatric SurgeryPlastic SurgeryOther SurgeriesTipo cirugia bariátricaBariatric Surgery of interestGastric Sleeve SurgeryGastric Bypass Surgery (Roux En Y)Revision Bariatric SurgeryIntragastric BalloonDuodenal SwitchMini Gastric BypassAllurion BalloonSpatz3 BalloonBariclipI want to know best option for meTipo cirugia plásticaPlastic surgery of interestBreast ImplantsLiposuctionTummy TuckMini Tummy TuckButt LiftPost-Bariatric Plastic SurgeryBreast ReductionBreast LiftBreast AugmentationFull FaceliftMini FaceliftMid FaceliftBrow LiftRhinoplastyBlepharoplastyEyelid surgeryOtra CirugÃaOther SurgeriesHerniaGallbladderKidney stonesFatty liverAbdominal bloatingUpper endoscopyRefluxI want to know the best optionEdad *Fecha Nacimiento *Sex *Sex*FemaleMaleCelular *Teléfono CasaDirecciónC.P *CiudadEstadoPaÃs *Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLao People’s Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint HelenaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. MartinSt. Pierre & MiquelonSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaSão Tomé & PrÃncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Virgin IslandsUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweEstado CivilReligiónWeight InformationPeso *Altura *Altura *IMC *Blood TypePersonal Pathological HistorySÃntomas que ha tenido durante los últimos 6 meses *Mark any of the following symptoms you have experienced during the last 6 months:*Sleep apneaInsomniaFeverHeadachesWeight loss/gainBruisingGingivitisDizzinessLower back painNone of the above mentionedEnfermedades que tiene o ha tenido *Mark any diseases you are experiencing:*Thyroid diseaseAnemiaArthritisDiabetesEpilepsyCardiac diseaseCancerAsthmaHigh blood pressureHepatitis CPsychiatric disordersHIVTuberculosisOther hepatitisNone of the above mentionedsurgery before*Have you had any surgery during your lifetimeYesNoPrevious surgeryPrevious surgeryCholecystectomy (gallbladder)Hysterectomy (uterus)Weight lossOtherFor previous Weight Loss SurgeryWhich type of Weight Loss SurgeryOther surgeriesWhen – Previous SurgeryTransfusions *Transfusions*YesNoWhen?Allergy to any medications *Allergy to any medications*YesNoWhich? *Non-Pathological HistorySmoking *Smoking*YesNoIf the answer is Yes, since when?Drug use *Drug use*YesNoIf the answer is Yes, since when?Alcohol Use *Alcohol Use*SÃNoIf the answer is Yes, since when?Exercise *Exercise*SÃNoIf the answer is Yes, since when?Hereditary InformationHereditary InformationMark if anyone in your family (father, mother, siblings or children) have or have had any of the following diseases:Thyroid diseaseCardiac diseaseCancerObesityArthritisStrokeDiabetesHigh blood pressureCurrent MedicationsName of medicationDoseForm of administrationHow oftenSince whenGyneco-Obstetric HistoryNo. pregnanciesVaginal deliveriesC-sectionsMiscarriagesCurrent pregnancy *Current pregnancy*YesNoDate of Last PregnancyOral contraceptives *Do you use or have used oral contraceptives?*YesNoOral contraceptives – WhichOral contraceptives – DoseDate of last periodMenopause *Menopause*YesNoMenopause – DateHormone replacement therapyHormone replacement therapy*YesNoHormone replacement therapy – TypeSince When?Emergency ContactEmergency Contact – Name *Emergency Contact – Phone *Emergency Contact – Relation * Submit
