Health History Form
The information you provide will help us plan your treatment

PATIENT INFORMATION:

Dr. Fernando Garcia Dra. Marcela Olague
Male Female
Other

PRIMARY HEALTH CARE PROVIDER:

PLEASE PROVIDE EMERGENCY CONTACT INFO:

Your Measurements
Torso Hips & Thighs

MEDICAL INFORMATION:

ALLERGIES:

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

CURRENT MEDICATION (INCLUDE VITAMINS, HERBAL SUPPLEMENTS, OVER-THE COUNTER MEDICATION, ETC):
Note: Pl. fill the below fields using commas separations as shown below

Name of medication Dose How often taken Purpose When use started Check the appropriate box
Required As needed
Required As needed
Required As needed
Required As needed
Required As needed
Required As needed
Required As needed
Required As needed
*IMPORTANT TO WOMEN
The time required to qualify for bariatric surgery must be at least 9 months from your last pregnancy, childbirth, cesarean section, or abortion.
If you are using a birth control that contains hormones, you should stop it for at least one or two months before your bariatric procedure and three months after your procedure and go to your gynecologist for the adjustment of hormone treatment, as it increases the risk of blood clots blood.
Yes No
Yes No
Yes No

LIST OF ANY MAJOR ILLNESSES:

Please identify which of the following serious illnesses you have been diagnosed with:
Hepatitis AIDS/HIV - any infectious diseases Colitis
Kidney Disease Bleeding Disorder Thyroid disorder
Irritable Bowel Rheumatoid Arthritis Multiple Sclerosis
Blood Clot / Thrombosis Sickle Cell Disease Fibromyalgia
Heart problems Endocrionological disorders Anemia
Illness Date Treatment Outcome
*If additional illnesses, please use comment box at bottom of page

LIST ALL SURGERIES YOU HAVE EVER HAD:

Surgery Date Reason
Yes No

FAMILY HISTORY:
Note: Pl. fill the below fields using commas separations as shown below

Please indicate if there is a family history of:
Obesity Kidney Disease Lung Disease, asthma, emphysema Diabetes
High Blood Pressure Bleeding tendency or blood disorder Heart Disease Breast Cancer
High Cholesterol Blood Clot Colon Cancer Pulmonary Emboli (blood clot to lung)
Sickle Cell Disease Infectious Diseases    
Family member Living Current Age or at death Cause of Death Health Problems
Mother* Yes No Yes No
Father* Yes No Yes No
Yes No Yes No
Yes No Yes No

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

Heart Disease Yes No Diagnosis Year
Angina* Yes No
M.I. (myocardial infarct)* Yes No
Any cardiovascular disease* Yes No
Abnormal EKG* Yes No
Stress Test* Yes No
Arrhythmia* Yes No
High Blood Pressure* Yes No
Yes No
Yes No
Yes No
Yes No

RESPIRATORY SYSTEM:

Yes No
Yes No
Yes No

OTHERS:

Yes No
Yes No
Yes No
Yes No
 
Yes No
 

BONE OR JOINT PROBLEM:

Hips* Yes No Knees* Yes No
Ankles* Yes No Feet* Yes No
Back* Yes No    

Circulation:

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

MENTAL HEALTH:

Yes No
Yes No
Yes No

TOBACCO/ALCOHOL USAGE:

Yes No
Yes No
Yes No
Yes No
Now that you have completed our history form please take a moment to look it over one last time to assure that all questions have been answered completely.
It is very important that we help you prepare for surgery. Once you are sure that all question are answered, please submit the form.
Please enter your full name to verify that all the information you have provided is accurate to the best of your knowledge.
Please read and sign the following authorization:

I , authorize Dr. Fernando Garcia Govea, Dra. Marcela Olague and/or his designees to request medical information, if required, from any of the physicians that I have listed above, as a part of this health history questionnaire. The information that is to be requested from the physicians may include but is not limited to, History and physical exams, Discharge summaries, Consultation reports, Laboratory and image studies.
I certify that my health history information is true and correct and that I am not intentionally falsifying my health information or misleading in any way about my current health including intentionally leaving out health information. I further understand that any false statements regarding my medical history could result in cancellation of surgery and I would be responsible for all cost incurred by .