Thailand Gastric sleeve by DOODEE CENTER

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Please kindly answer the preliminary questionnaire. To send information to a medical professional for evaluation before consulting in the form Online

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Facebook Fan page : Thailand Gastrics Sleeve
whatsapp : +66902527778

"Because we only have one body Start taking care of yourself today DOODEECENTER"

Email *

Full Name (As Per Passport) *

Birth Date
*

YYYY

Gender *

Male

Female

Whatsapp Number
*

Body Weight (In Kg's) *

Height (In CM)
*

Nationality
*

Preferred Language *

What Procedures Do You Require? You may select more than one. *

What Results Do You Want To Achieve? *

Have you previously had cosmetic surgery? *

Do You Have Any Questions For The Surgeon? *

Diabetes or blood sugar problems? *

Please clarify diabetes / blood sugar problems *

Thyroid problems?
*

Heart problems?
*

Lung problems?
*

Blood pressure problems?
*

Kidney or liver problems?
*

Blood disorders?
*

Previous/current history of cancer
*

HIV or AIDS?
*

Nervous breakdowns/Depression?
*

Neurological problems?
*

Anaesthesia problems?
*

Do you suffer from Sleep Apnea? (Breathing stops for a period of time during sleep)
*

Have you ever had a Stroke or Transient Ischaemic Attack (TIA)?
*

Have you have had any medical conditions not mentioned above
*

Are You Female And Requiring Breast Surgery and/or Tummy Tuck Surgery?

Have you been hospitalized, had surgery or received medical care within the past 5 years (including cosmetic surgery)?
*

Do you have implants or metal objects in your body?
*

If you answered "Yes" to the above, please specify.
*

Do you have difficulty with healing or scarring?
*

Do you have any allergies to food, drugs etc?
*

List all medications you currently take and dosage you take for each.
*

List all vitamins or food/nutritional supplements you currently take and dosage.
*

Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?
*

Have you ever taken Daily Coumadin, Daily Heparin or Daily Aspirin?
*

Do You Smoke?
*

Do You Drink Alcohol?
*

When would you like to schedule the surgery? *

Consent

I declare that I have truthfully completed the entirety of this form and that I have not made any purposeful omissions.

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