Laparoscopic Bariatric Specialists International at Piyavate Hospital, Bangkok, Thailand Gastric Bypass Thailand Patients at Bangkok Hospitals
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Patient Information Form

The red asterisks (*) denote required fields which have to be filled in before the form can be submitted.

All information submitted by you will be treated confidentially.

Privacy Statement

We collect personal information to determine eligibility and to consult with each patient individually about our services. We maintain and use personal information responsibly. We do not sell or rent your information to third parties.

Has LBS ever rendered treatment to any family member?
Patient First Name: *
Last Name: *

Birth Date: * (Day Month Year)          		Age:* Years

Marital status:

Sex: *

Occupation (if retired, what did you do?):
 
E-mail: *
Telephone: *

Address: *
City: *
Province/State: *
Country: *
ZIP-Code: *
Fax:

Please describe here below in your own words what you hope to accomplish and how you hope your life will change by losing weight.

 


PATIENT HISTORY QUESTIONNAIRE

The information requested in this questionnaire is very important to give you the best care. Please answer completely and be thorough.

Item
Your measurements

Please select - are your weight measurements in pounds (lbs) or in kilograms (kg)?

Please select - are your height measurements in feet (ft) or in centimeters (cm)?

Actual body weight:
Height:
Ideal body weight:
Body frame:

Serious illnesses - have you had:
Hepatitis Blood transfusion HIV / AIDS exposure 
Colitis Kidney disease Bleeding abnormalities
Thyroid problems (please specify):

Please list all serious illnesses you have experienced in adulthood:

Serious illnesses
Date
Treatment

Please list all surgeries (including dates) that you have had.
If none, indicate 'None': *

 

Allergies

Are you allergic to any medications?

If yes, please list medicine and reactions here below.

Medication
Reaction

Any other allergies:

Medications
Please list below all medications you currently use.

Medication
Dose & frequency

Do you use tobacco?
If yes, are you willing to quit?

If you use tobacco, how many cigars / cigarettes per day?

Do you use alcohol?


If yes, then how frequent?

Psychological history
Nervousness Anxiety Depression
Thoughts of suicide Suicide attempts Psychiatric treatment
Psychological counseling Hospitalization for emotional problems

Other

List any other diets and/or weight loss methods you've tried

Weight related illnesses
Have you had, or do you have, any of the following illnesses or symptoms?

Heart Disease:
If yes, year diagnosed:

Do you have or have you had
Angina Abnormal EKG Palpitations
MI (myocardial infarction)
CABG (coronary artery bypass graft)

List medications:

High
Blood pressure:

If yes, year diagnosed:


List medications:

Diabetes:  
If yes, year diagnosed:
Gestational: Neuropathy:  

Asthma:
If yes, year diagnosed:

Sleep apnea syndrome:		  
If yes, year diagnosed:
Last sleep study:
Do you use CPAP?

Heartburn/esophagitis/
hiatal hernia:

If yes, year diagnosed:

Have you had:
An upper GI series?
An Endoscopy?

List medications:

Frequency of use:
Belching up acid or sour fluid:

Coughing or choking at night:
Gall bladder disease:

If yes, how was it diagnosed?
Ultrasound Physical exam
Leakage of urine with coughing/laughing/sneezing:
If yes, do you wear pads frequently?
Low back strain/pain/sciatica:
If yes, are you seen by a chiropractor?
...by an orthopedic surgeon?
...by a family doctor?


Medications Taken:
Pain in hips/knees/ankles/feet: 
If yes, are you seen by a chiropractor?
...by an orthopedic surgeon?
...by the family doctor?
Medications Taken:

Weight-Related Injuries and Traumas:
Venous stasis disease:
If yes, do you have edema?
Do you have scaly and thick skin?
Do you have leg ulcers?
Gout:
If yes, goury arthritis?


Medications Taken:

Additional Comments:


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