2019 MSWL and Orbera New Patient Forms
Please complete this form to the best of your ability. Medically Supervised Weight Loss products are not covered by Insurance. Orbera Gastric Balloon is not covered by insurance. We will explain fees to you before services are rendered.
Email address *
Please add your First Name, Middle Initial, Last Name: *
Your answer
What is your date of birth? *
Your answer
List your approximate Height and Weight
Your answer
Enter your address *
Your answer
Enter the best telephone # to reach you: *
Your answer
How did you hear about our program
Your answer
Enter your primary care physician's name:
Your answer
Do you have any allergies? *
If yes, please list allergy and reaction
Your answer
Please list your medications:
Your answer
Please list any previous surgery or surgeries:
Your answer
Please check Yes or NO for the following: *
Yes
No
Alcohol Abuse
Anemia
Asthma
Auto-immune Disease or diseases
Bleeding or Clotting Disorder
Blood Clot (PE) Pulmonary Embolism
COPD
Cirrhosis of the Liver
Diabetes TYPE 1
Diabetes TYPE 2
History of Diabetes when Pregnant
GERD or REFLUX
Heart Disease
Hepatitis or Liver Disease
High Blood Pressure (HTN)
High Cholesterol or lipids
History of Cancer
History of Chronic Pancreatitis
Arthritis
Back pain, knee pain, hip pain
History of a STROKE
History of Nausea with Anesthesia
History of problems with Anesthesia
Kidney or renal disease
Neurological disease
Urinary disease
Depression or history of depression
History of a mental disorder
History of a physical disability
History of illicit Drug Use
Portal Hypertension
History of seizures or epilepsy
Sleep Apnea
Sleep apnea with use of a CPAP
Steroid use in the past 2 months
TB (tuberculosis)
Current use of tobacco or cigarette smoking
History of ulcer (gastric or duodenal)
Please check all previous diet attempts *
Required
What is the most weight that you lost with the above methods:
Your answer
What is your personal weight loss goal
Your answer
Do you have ANY food allergies or intolerances *
Required
Do you currently take any vitamins, minerals, or herbal supplements
Your current dietary intake *
1 or less
2-4
More than 4
How many meals per day
How many snacks per day
How many beverages with calories per day
How many days per week do you exercise
How many times per week do you dine out
Do you have cravings or trigger foods
Your answer
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