Angeles Health Bariatric Treatment Questionnaire



Your information is held in the strictest confidence. Your personal information will never be sold for marketing purposes, and will only be used to contact you in matters strictly related to your medical travel experience.

It is essential this form be filled out completely in order for the medical treatment team to properly assess your suitability for the procedure you are inquiring about. Incomplete information may result in delays in setting up necessary medical consults or finalizing your quote. Please be as thorough as possible in describing your relevant medical history, indications, diagnoses, and medications.
We take the privacy of your information very seriously; we use only HIPAA-compliant systems and processes in the accessibility, transfer and review of your medical records. Checking the boxes below indicates your understanding that:


I agree to my personal medical profile being reviewed by Angeles Health International for completeness before securely transmitting it to the surgeon for evaluation.

Patient Name:*  
Procedure Date:
Email Address:*
Date of Birth:
Body Mass Index:
Emergency Contact:
Marital Status:
Primary Doctor:
Primary Dr Phone:
Primary Dr address:
Office Phone:
Mobile Phone:
Home Phone:*
Work Phone:
Referring Doctor:
Referral Dr Phone:


Question Responses
Are you currently employed? Yes No

Do you have a family history of any of the following and if so, please indicate

Question Responses
Heart Disease
Snoring/Sleep Apnea
High Cholesterol
Hip Fractures

Please indicate your weight at the following times. Please indicate whether your weight was below average, average, above average or very heavy. Current Weight and BMI are indicate in the Summary on top of the Profile!

Question Responses
Birth Weight
Weight at age 10-12
Weight at age 15-18
Weight at age 21
Weight at time of marriage (if applicable)

Current Weight and Lifestyle

Question Responses
How would you describe your body shape:
Current waist size:
Current hip size:
How many years have you been overweight?
Weight trend in the last 6 months:
Exercise habits:
Eating Habits: How many meals per day, snacking between meals, binge eating, sweets, fast food soda:
Drug use (currently and in the past): Yes No
Psychiatric Disorders (currently and in the past), when was the diagnosis made? Yes No
Hospitalization for psychiatric disorders? Yes No

Dieting and Weight Loss History

Question Responses
Weight Watchers
Fad Diets
Appetite Suppressants
Details of any other weight loss measures (including surgical)
Where there any particular events that lead to significant weight gain?

Question: Have you ever suffered from any of the following health problems? If yes, please provide details such as dates, diagnosis, and duration of illness. NOTE: If no details are provided the question will not appear.

Question Responses
Diabetes Yes No
Diabetes Details
Diabetes while pregnant Yes No
Arthritis or Joint Pain Yes No
Back Pain Yes No
Kidney or Urinary Disorder Yes No
Neurological Yes No
Psychological/Nervous Disorder Yes No
Gallstones Yes No
Gastric or Duodenal Ulcer Yes No
Hepatitis or Liver Disease Yes No
High Blood pressure Yes No
High Blood pressure Details
Heart Disease Yes No
High Cholesterol Yes No
High Cholesterol Details
Anemia or Bleeding Disorder Yes No
Thrombosis or Clotting Disorder Yes No
Varicose Veins or Leg Swelling Yes No
Eczema or Skin Condition Yes No
Hay fever or Rhinitis Yes No
Allergies Yes No
Surgical History
Major Illnesses
Medication - psychiatric Yes No
Medication - psychiatric details
Medication - migraine Yes No
Medication - weight loss Yes No
Medication - epilepsy Yes No
Medication - asthma Yes No
Medication - hormones Yes No
Medication - HRT Yes No
Medication - cortisone Yes No
Medication - last 12 months Yes No

Surgical History

Question Responses
Please give details of any past operations:


Question Responses
Allergies (including foods, medications, dressings)

Question: Please indicate whether you are now or have previously taken any of the following medications. If yes, please state the name of the medication and how long you have been or were taking it.

Question Responses  
Medication for psychiatric disorder Yes No
Migraine medication Yes No
Medications to assist weight loss Yes No
Drugs for epilepsy Yes No
Drugs for asthma or breathing Yes No
Hormones, e.g.The Pill Yes No
HRT Yes No
Cortisone Yes No
Please list in detail all medications that you have used in the last 12 months. Please include any dietary supplements, creams, eye drops, etc.
What medications are you currently taking?


Question Responses
Please include your main daily routines and describe your main social/familiar environment.
Example: Jeff 44 Patient requesting surgery. Wife Anna 36. Three biological children: Kevin 16, Pamela 14. They live with their mom and visit on vacation. Stephen 7. Work: office manager. Sedentary job. Working hours: Mon -Sat 9 to 6. Have an hour lunch break. Excercise: hiking only every other weekend. Recreational activities: eating out with family, taking Stephen to playground or the movies. Some nights beer with friends.
What do I want to get out of this weight loss surgery besides losing weight?
Why am I choosing this surgery over the other ones?

Sleep History

Question Responses
On average, how many hours of sleep do you get a night?
Is there anything that keeps you awake at night? Yes No

NOTE: The answers are rated from Never to Always with never being 0 and always being 5

Question Responses
How often do you snore?
Do you wake during the night with a choking feeling?
How often do you snore?
How often would you sleep more than 8 hours in total in a 24 hour period?
Do you feel sleepy during the day?
Has anyone noticed that you momentarily stop breathing during your sleep?
How often do you doze off or fall asleep while driving?
How often do you wake up more than once during the night?
Do you have a headache when you wake up in the morning?
Do you fall asleep while reading?
Do you wake up in the morning feeling confused?
How often do you have a nap during the day?
Have you or anyone else noticed a change in your personality recently?
Do you feel sleepy in the evenings?

NOTE: The answers here are rated from no chance to slight chance to moderate chance to high chance

Question Responses
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g. theatre or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Activity Level

Question Responses
How many sessions of exercise (walking, sports, etc) do you do per week for more than 30 minutes at a time?
What sort of activities?
How do you feel when exercising? Use a scale of 1-10, where 1 is awful and 10 is excellent.

Smoking & Alcohol

Question Responses
Do you drink Yes No
Do you currently smoke? Yes No
Have you smoked in the past? Yes No
If yes, how many per day?
For how many years
When did you stop smoking?
Do you drink any alcohol? Yes No
How often do you have a drink containing alcohol?
What is the main alcoholic beverage you drink? (choose one)
What others do you drink occasionally? (choose all that apply)
When do you mainly drink? (choose one)
At what other occasions do you drink? (choose all that apply)

Breathing History and Asthma

Question Responses
Asthma Yes No
Respiratory/Breathing Problems Yes No
Does being at work ever make your chest tight or wheezy? Yes No
Have you ever had asthma? Yes No
Have you ever had to change a job because it affected your breathing? Yes No
Have you ever worked in a job which exposed you to vapors, gas, dust, or fumes? Yes No
Have you ever had to spend a night in hospital because of asthma/breathing problems? Yes No
If yes, was it in the last 12 months? Yes No
In the last 12 months, have you visited an emergency room or seen a doctor urgently because you had asthma or breathing problems? Yes No
In the last 12 months, have you taken a course of Prednisolone because of asthma or breathing problems? Yes No
In the last 12 months, have you missed work or school because of asthma or breathing problems? Yes No
Do you usually have a cough? Yes No
Do you usually bring up phlegm from your chest when you cough? Yes No
Do you get short of breath on exertion? Yes No
Do you get short of breath walking on flat ground? Yes No
Do you get short of breath walking uphill or doing housework? Yes No
In the last 12 months, have you had an attack of shortness of breath that came on when you were not exerting yourself and without obvious cause? Yes No
In the last 12 months, have you had wheezing in your chest? Yes No
In the last 12 months, have you had an attack of wheezing that came on after you stopped exercising? Yes No
In the last 12 months, have you had a feeling of tightness in your chest on waking in the morning? Yes No

Gastroesphageal Reflux Indigestion

Question Responses
Reflux or Heartburn Yes No
Do you have a history of heartburn or indigestion? Yes No
If yes, how often do you have reflux during the day?
Do you suffer heart burn or indigestion during the night? If so, how often?
What aggravates or causes your reflux?
Do you have difficulty swallowing? Yes No
Does food ever get stuck? Yes No
Does food or fluid reflux into the mouth? Yes No
Do you vomit with reflux? Yes No
Do you suffer from recurrent sore throats? Yes No
Do you suffer from a hoarse voice? Yes No
Do you suffer from a regular cough at night? Yes No
Please list any treatments you may use for reflux / heartburn or indigestion

Dietary Supplements

Question Responses
Do you take multivitamin tablets or other dietary supplements? Yes No
Do you take folate tablets? Yes No


Question Responses
Do you have regular periods (26 - 33 days)? Yes No
If not, please describe
Do you have problems with excessively heavy periods? Yes No
Have you had difficulty in conceiving in the past? Yes No
Do you currently have problems with infertility? Yes No
Have you suffered from excess body hair or acne? Yes No
Have you ever been told by a doctor that you have polycystic ovaries? Yes No
Have you had problems with pregnancy and/or childbirth? Yes No
Have you had a caesarean section? Yes No
If yes, why?
Have you noticed a reduction in your libido or sex drive? Yes No