Bariatric surgery form

Desired intervention

Your current weight (in Kg)

What maximum your maximum weight reached? (in kg)

Your Height (in cm)

Waist size

Your waist measurement (in cm)

Duration of evolution of obesity

What are your eating habits?

Mostly Sweet

Mostly Salty

Salty and sweet

Fatty meals (Fast Food, etc.)

Do you consume sweetened liquids?

Not often

Yes

No

Do you eat large meals often?

Not often

Yes

No

Do you snack?

Not often

Yes

No

What do you eat between meals?

Do you drink alcohol in large quantities?

Not often

Yes

No

How many meals a day do you eat? and at what time of day?

Other comments on your eating habits? Please specify

Do you have associated diseases (diabetes, hypertension, coronary insufficiency, endocrine diseases, joint diseases, sleep apnea, respiratory diseases, cancers, infertility, psychiatric diseases, others…)? Please specify

Do you have any digestive diseases (gastroesophageal reflux disease, ulcer, cirrhosis, Crohn's disease, tumours, other…)? Please specify

Do you take long-term medication? Please specify

Do you have any allergies (medicinal, other…)? Please specify

Have you ever had any surgery? thank you for specifying (nature, by which way ..)

Have you ever had surgery for obesity? Please specify (date, nature, approach, result, complications, etc.)

Is obesity hereditary? Please specify

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Personal informations

Medical information