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1-on-1 Bariatric Nutrition Medical Form

YOUR SAFETY DEPENDS ON THE ACCURACY OF THE INFORMATION PROVIDED.

Please fill out the form and then click SUBMIT. You will receive a confirmation when the form has been sent.
*All fields with an asterisk are mandatory.

    Personal information










    Other Information






    Questionnaire


    YesNoDo Not Know





    YesNoDo Not Know





    YesNoDo Not Know





    YesNoDo Not Know





    YesNoDo Not Know





    YesNoDo Not Know





    YesNoDo Not Know





    YesNoDo Not Have Periods





    YesNo





    YesNo





    YesNo




    FOR THE FOLLOWING QUESTIONS, PLEASE INDICATE "YES" "NO" OR "DO NOT KNOW".

    * PLEASE ANSWER ALL OF QUESTIONS.
    1. Do you currently take any of the following medications

    YesNoDo Not Know


    YesNoDo Not Know


    YesNoDo Not Know


    YesNoDo Not Know


    YesNoDo Not Know


    YesNoDo Not Know


    YesNoDo Not Know




    2. Have you ever been treated for cancer with chemotherapy or radiation therapy?
    YesNo




    3. Do you currently have any problems with your:

    YesNoDo Not Know


    YesNoDo Not Know


    YesNoDo Not Know


    YesNoDo Not Know




    4. Have you or anyone in your family ever had a serious bleeding problem?
    YesNoDo Not Know




    5. Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed?
    YesNoDo Not Know




    6. Do your gums bleed when you brush your teeth?
    YesNoDo Not Know




    7. Are you pregnant?
    YesNoDo Not Know




    8. Is there a possibility that you are pregnant?
    YesNoDo Not Know




    9. Have you been told you have diabetes?
    YesNoDo Not Know




    10. Do you wake up to urinate more than once at night?
    YesNoDo Not Know




    11. Do you have muscle cramps or pains?
    YesNoDo Not Know




    12. Do you have problems with your lungs or chest? (e.g. chest pain, skipped heart beats, high blood pressure, smoke one or more packs a day, shortness of breath, emphysema, asthma, bronchitis)
    YesNoDo Not Know




    13. Do you have a cough, or cough frequently?
    YesNoDo Not Know




    14. Do you have epilepsy, or suffer from fits or seizures?
    YesNoDo Not Know




    15. Do you have neck or back problems?
    YesNoDo Not Know




    16. Are you scheduled to have an operation?
    YesNoDo Not Know