Download PatientInformationGuide.doc
Download Pre-OperativeAssessmentForm.doc
Download Pre-SurgeryQuestionnaire.doc

Please fill out and e-mail back or give to the Doctor BEFORE surgery. This is helpful info for the doctor to have, especially if you have any other medical problems. You always want your surgeon to be well-informed.

If you have wish to expand in any area or have additional information  that is important the doctor know please add on to this form.    

YOUR SAFETY DEPENDS ON THE ACCURACY OF THE INFORMATION PROVIDED.

Fill the forms and then click SUBMIT. If you do not get confirmation your forms were not sent.

 

Pre-Surgery Questionnaire
 
Procedure:   Patient facilitator name:  
 

*Name:

*Height:

*Age:

  

E-mail:

*Weight:

*BMI:

  

 Address:

City, state, zip 

                                      *Telephone:

 Home:  Cell :

Maximum Weight:

When?
 

 

*List all Medicine Allergies:

Date of Birth:

Date of surgery:

*Name of person to contact_
(in case of emergency):

*Emergency_
Phone #:

*Any Medical/physical problems (i.e., sleep apnea, high blood pressure,
diabetes, high cholesterol, blood diseases, neurological disorders, etc)?
No Do Not Know

If Yes, please list:

  Are you currently taking any medications or herbal supplements?
No Do Not Know

If Yes, please list the name, dosage
and reason for this medicine):

Is there any history in your family of diabetes, cancer and/or hypertension?
No Do Not Know

If Yes, please indicate which ones:

Any  surgeries (i.e., gallbladder, appendix, hernia, heart, etc.)?
No Do Not Know

If Yes, please list:

Do you have any adverse reaction to anesthesia?

No Do Not Know

If Yes, please indicate the reaction:

Do you have dentures, dental implants, or caps?

No Do Not Know

If Yes, please indicate where:

Do you have any children? If so, how many?

 
No

Do you have heavy periods?

   
No

Do you smoke? If so, how many cigarettes a day?

  
No

Do you drink?  If so , how many?

  
No

Do you do drugs? If so, what kind & how often?

  
No
 

Pre-Operative Assessment
 

Patient Name

Age

Sex

Date 

For the Following Questions, Please Indicate “Yes” “No” or “Do Not Know”.  Please answer all of the questions.

  1.   Do you currently take any of the following medications?

a)    Aspirin (excedrin, anacin, bufferin)
No Do Not Know

b)    Anticoagulants (blood-thinning medicine)
No Do Not Know

c)     Propanol, Verapamil (heart rhythm medicines)
No Do Not Know

d)    Diuretics (water pills)
No Do Not Know

e)    Antihypertensive drugs (blood pressure pills)
No Do Not Know

f)     Digitalis (heart pills)
No Do Not Know

g)    Stereoids (prednisone, cortisone)
No Do Not Know

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

If yes: when:

No Do Not Know

  3.   Do you currently have any problems with your:

a)    Liver (e.g. cirrhosis, hepatitis, yellow jaundice)
No Do Not Know

b)    Kidneys (infection, stones, failure)
No Do Not Know

c)     Spleen
No Do Not Know

d)    Blood (anemia, leukemia)
No Do Not Know

  4.   Have you or anyone in your family ever had a serious bleeding problem?
No Do Not Know

  5.   Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed?
No Do Not Know

  6.   Do your gums bleed when you brush your teeth?
No Do Not Know

  7.   Are you pregnant?
No Do Not Know

  8.   Is there any possibility that you are pregnant?
No Do Not Know

  9.   Have been told you have diabetes?
No Do Not Know

10.   Do you wake up to urinate more than once at night?
No Do Not Know

11.   Do you have muscle cramps or pains? 

No Do 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) if yes please list: 

No Do Not Know
 

13.   Do you have a cough, or cough frequently?
No Do Not Know

14.   Do you have epilepsy or suffer from fits or seizures?
No Do Not Know

15.  Do you have neck or back problems?
No Do Not Know

16.   Are you scheduled to have an operation?
No Do Not Know

          If Yes, what operation?

17.   Are you currently taking any medications?
No Do Not Know

If Yes, please list:
   

The recommended surgery for obese patients with GERD or severe acid reflux is the Gastric Bypass. The bypass is the anti reflux surgery for weight loss. The sleeve can actually cause more reflux that may or may not be controlled with medication. In the case that the reflux is not controlled by medication you will need to consider converting your sleeve into a gastric bypass to prevent serious repercussions from the acids
 
Did anyone refer you?   Yes   if yes, please write referer's name

 

 
 
Mexicali Bariatric center
Madero 1119-2, Colonia Nueva | Mexicali, BC 2110
U.S. TOLL FREE: 1-888-344-3916 | Fax: 619-923-2600