Medical History Form
First name
Last name
Email
Phone number
Age
Country/Region
City
Height
Weight
Have you ever tried to follow a diet programme?
Yes
No
What was the reason behind your failure with a diet programme?
Which surgery option would you like to have for loosing weight?
Gastric Sleeve Surgery
Gastric Bypass Surgery
Revision Surgery
I'm not sure which is best for me
Other
Is this going to be your first weight loss surgery?
Yes
No
Which surgery did you have before for losing weight?
Have you had any major illness?
Do you have any chronic and important disease? If yes, please explain. This question is required.
No, I don't have any disease
Type 2 Diabetes
Heart Disease
Hypertension
Gout
Gallstones
Snoring Sleep Apnea
Asthma
Dermatitis Eczema
High Cholesterol
Osteoporosis
Hip Fractures
Joint Pain
Type 1 Diabetes
Reflux or Heartburn
Gastric or Duodenal Ulcer
Neurologic Disorder
Other
Do you have any regular medicine usage?
Yes
No
Do you have to take blood thinners regularly?
Yes
No
Can you explain your disease in detail? For how long do you have it, what is the name of the medicines and dozes?
Please, list all the surgeries you had until today.
Are you allergetic to anything?
Yes
No
Are you on any special diet?
Vegan
Vegetarian
Ketogenic
Dukan
Diabetic
Gluten-free
Intermittent Fasting
I'm not a diet fan
Do you drink alcohol?
Yes
No
Do you smoke?
Yes
No
Have you stopped smoking? When?
Have you ever had any problems with anesthesia before?
Yes
No
Which bariatric surgeon would you prefer?
The one is available at the soonest appointment
Assoc. Prof. Dr. Hasan ABUOGLU
Assoc. Prof. Dr. Mehmet Kamil YILDIZ
Which date do you prefer to come to Istanbul and get your surgery done?
/
/
Are you bringing someone with you ? (It's totally free of charge, he/she can stay with you in your private room, and will have the daily meals)
Yes
No
Are you ready for a big change in your weight, appearance, and lifestyle? Tell us a little bit about your new beginning goals
Submit
