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Please fill in carefully this questionnaire in order to get the most accurate and helpful answers from the Advanced BMI Doctors. If you need any help, call us at +961 76 377 376 or +961 04 718 635
DEMOGRAPHIC INFORMATION
First Name
*
Your answer
Last Name
*
Your answer
Email
*
Your answer
Confirm Email
*
Your answer
Phone
*
Your answer
Date of Birth
*
Your answer
Countrty
*
Your answer
Occupation
Your answer
Martial Status
Single
Married
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Do you have Children
Yes
No
Clear selection
What is you weight
*
Kilograms
Your answer
What is your height
*
Your answer
Referring Doctor Name and Phone (if applicable)
Your answer
ALLERGIES / PERSONAL HABITS
Do You have allergies
*
Yes
No
If You have allergies, Give Details
Your answer
Do You smoke
Yes
No
Clear selection
Do You drink alcohol more than a "social drinker"
Yes
No
Clear selection
FAMILY HISTORY
Is there anyone in your family (parent, brother, sister) have any of the following
Obesity
Diabetes
Heart disease
High Blood Pressure
High Cholesterol
Snoring / Sleep Apnea
REVIEW OF MEDICAL PROBLEMS
Do you have High Blood Pressure
*
Yes
No
Do you have any problems with your heart
Example: heart attack, chest pain
Yes
No
Clear selection
Do you have High Cholesterol
Yes
No
Clear selection
Do you have High Lipids
Triglycerides
Yes
No
Clear selection
Do you have Diabetes
*
Yes
No
Do you have have Asthma
Yes
No
Clear selection
Do you have frequent lung infections
Example: bronchitis, pneumonia
Yes
No
Clear selection
Have you had blood clots in your legs
Yes
No
Clear selection
Have you had blood clots in your lungs
Yes
No
Clear selection
Can you walk two flights of stairs without stoping
Yes
No
Clear selection
Are you tired all the time
Yes
No
Clear selection
Do you have acid reflux
Yes
No
Clear selection
Do you lose urine when you laugh or cough
Yes
No
Clear selection
Have you any kidney problems
Example: infections, stones
Yes
No
Clear selection
Have you ever had bleeding problems
Example: bleeding that does not stop easily
Yes
No
Clear selection
Do you suffer from depression
Yes
No
Clear selection
Do you suffer from an eating disorder
Yes
No
Maybe
Clear selection
Do you have hip pain
No
Mild
Moderate
Severe
Clear selection
Do you have knee pain
No
Mild
Moderate
Severe
Clear selection
Do you have ankle pain
No
Mild
Moderate
Severe
Clear selection
Do you have feet pain
No
Mild
Moderate
Severe
Clear selection
Do you have back pain
No
Mild
Moderate
Severe
Clear selection
Do your ankles swell
No
Mild
Moderate
Severe
Clear selection
PAST SURGICAL HISTORY
Have you had previous surgery such as
None
Stomach
Gallbladder
Appendix
Uterus / Ovaries
Colon / Intestine
Describe the surgery
Your answer
FOR WOMEN ONLY
Do you have regular periods
Yes
No
Do you have excessively heavy periods
Yes
No
Do you currently have infertility
Yes
No
Do you have Polycystic Ovarian Syndrome
Yes
No
Have you had abnormal glucose levels during pregnancy
Yes
No
FOR MEN AND WOMEN
Medications You are taking
Your answer
Anything else you want to tell us
Your answer
I am primarily interested in the following
*
Diet Program without surgery
Gastric Bypass
Gastric Sleeve
Gastric Plication
Gastric Banding
Duodenal Switch
Revision of previous surgery
Single Incision Gastric Sleeve
Single Incision Gastric Banding
Gastric Balloon
Liposuction
Tummy tuck
Arm Lift
Thigh Lift
Breast Lift & Augmentation
Rhinoplasty
Blepharoplasty
Face and Neck Lift
Brazilian Butt Augmentation and Lift
Fat Transfer
Required
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