info@longtermvsg.com
Pre Op Form English
Pre Op Form Spanish
Procedure:
ChooseGastric BypassGastric SleeveMini Gastric BypassRevision SurgeryLap BandPlastic Surgery
Patient facilitator name:
First Name*
Last Name*
Age:
E-mail:*
Height:*
Weight:
BMI:
Address:
Street Address:
City:
State / Province / Region:
Postal / Zip Code:
Country:
—Please choose an option—AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe
Phone (Home):*
Phone (Cell):
Maximum Weight:
When?:
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.)?*
YesNoDon't Know
If Yes, please list:
Are you currently taking any medications or herbal supplements?
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?
If Yes, please indicate which ones:
Any surgeries (i.e., gallbladder, appendix, hernia, heart, etc.)?
Do you have any adverse reaction to anesthesia?
If Yes, please indicate the reaction:
Do you have dentures, dental implants, or caps?
If Yes, please indicate where:
Do you have any children?
YesNo
If so, how many?
Do you have heavy periods?
Do you smoke cigarettes?
If so, how many cigarettes a day?
Do you drink?
If so, how many drinks?
Do you do drugs?
If so, what kind and how often?
Patient Name:
Patient Age:
Patient Sex: MaleFemale
Date:
a) Aspirin (excedrin, anacin, bufferin)
b) Anticoagulants (blood-thinning medicine)
c) Propanol, Verapamil (heart rhythm medicines)
d) Diuretics (water pills)
e) Antihypertensive drugs (blood pressure pills)
f) Digitalis (heart pills)
g) Stereoids (prednisone, cortisone)
1. Do you smoke one or more packs a day,
2. Have you ever been treated for cancer with chemotherapy or radiation therapy?
If Yes, When:
3. Do you currently have any problems with your:
a) Liver (e.g. cirrhosis, hepatitis, yellow jaundice)
b) Kidneys (infection, stones, failure)
c) Spleen
d) Blood (anemia, leukemia)
4. Have you or anyone in your family ever had a serious bleeding problem?
5. Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed?
6. Do your gums bleed when you brush your teeth?
7. Are you pregnant?
8. Is there any possibility that you are pregnant?
9. Have been told you have diabetes?
10. Do you wake up to urinate more than once at night?
11. Do you have muscle cramps or pains?
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,(1)
shortness of breath, emphysema, asthma, bronchitis) if yes please list:
13. Do you have a cough, or cough frequently?
14. Do you have epilepsy or suffer from fits or seizures?
15. Do you have neck or back problems?
16. Are you scheduled to have an operation?
If Yes, what operation?
17. Are you currently taking any medications?
If Yes, please list medications:
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?*
Pleas tell us how you found out about Long Term VSG:
Select valueTelephoneYoutubeGoogleYahooBingWhatclinicObesity HelpReal SelfBariatric PalBlog
if yes, please write referer's name
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