Health Check Form Obesity

Name

Surname

Email

Birth Day

Occupation

Height

Weight

BMI Index

Country

Phone Number

Address/City/State

Have you had any operations?

Have you ever been hospitalized for reasons other than operations?

Please list all medicines you take now and specify doses: (include over-the-counter medicines and supplements)

Please list any allergies or reactions

Blood transfusion
Yes No

Anemia
Yes No

Asthma/Emphysema
Yes No

Arthritis
Yes No

Bladder or Kidney Infections
Yes No

Blood Clots / Bleeding disorders
Yes No

Chronic Diarrhea
Yes No

Diverticulosis
Yes No

Diabetes
Yes No

Epilepsy or Seizures
Yes No

Gallstones / Gallbladder Disease
Yes No

Gout
Yes No

Heart Disease
Yes No

Cholesterol
Yes No

High Blood Pressure
Yes No

Kidney Disease/Stones
Yes No

Liver Disease/Hepatitis
Yes No

Lung Disease/Pneumonia
Yes No

Polyps
Yes No

Rheumatic Fever
Yes No

Sleep apnea
Yes No

Stroke
Yes No

Thyroid Disease/Goiter
Yes No

Ulcers (stomach or intestinal)
Yes No

Reflux
Yes No

Sexually-transmitted disease
Yes No

Smoking:
Yes No

Alcohol:
Yes No

Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics, diet pills?

Notes


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