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Patient facilitator name:
State / Province / Region:
Postal / Zip Code:
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Date of Birth:
Date of Surgery:
Name of person to contact in case of emergency:
*Any Medical/physical problems (i.e., sleep apnea, high blood pressure, diabetes, high cholesterol, blood diseases, neurological disorders, etc.)?*
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.)?
If Yes, please list:
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?
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 Sex: MaleFemale
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)
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:
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if yes, please write referer's name
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