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EN: +1 647 812 1159

Bariatrics Form

Patient Information Sheet and History

For your safety and to enable our doctors to make the best diagnosis and respond to you as quickly as possible in a clear and precise manner, we ask that you accurately fill in all information relating to your medical history and/or your chronic illnesses (if they exist).

Sex
This questionnaire is completed by:
Response to diets
Sucre
Salty
Large meal
Snacking
Alcohol
Sweet liquids
Diabetes
HTA “Hyper Blood Pressure”
Coronary insufficiency
Endocrine diseases
Joint diseases
Sleep apnea
Respiratory diseases
cancers
Infertility
Psychiatric illnesses
Gastroesophageal reflux
Ulcer, cirrhosis
Crohn's disease
Tumors
Medicinal
Please specify the Date, Nature, Approach, Result and Complications
Heredity:
Have you suffered or do you suffer from high blood pressure?
Have you suffered or do you suffer from angina?
Have you had a heart attack?
Have you had any heart rhythm problems?
Do you have a pacemaker?
Have you had phlebitis?
Have you suffered or do you suffer from asthma?
Have you suffered or do you suffer from chronic bronchitis?
Have you suffered or do you suffer from emphysema?
Have you suffered or are you suffering from pulmonary embolism?
Do you sleep with a CPAP for Obstructive Sleep Apnea Syndrome?
Have you had a stomach/duodenal ulcer?
Have you had esophagitis?
Have you had a hiatal hernia?
Have you had hepatitis (jaundice)?
If so, which one?
Have you suffered or do you suffer from diabetes?
Have you suffered or do you suffer from thyroid problems?
Have you suffered or do you suffer from depression?
Have you suffered or do you suffer from migraines?
Have you suffered or do you suffer from epilepsy?
Have you suffered or do you suffer from Parkinson's disease?
Have you suffered or do you suffer from myopathy?
Have you had a stroke or head injury?
- Have you suffered or do you suffer from any other illnesses?
Have you ever had surgery?
Please specify the date of the interventions.
Has a family member had a myocardial infarction?
Are you pregnant?
Have you ever had anesthesia?
Did you have any complications during the anesthesia?
Did you have any complications after the anesthesia?
Has a family member experienced a problem during anesthesia?
Have you had a latex allergy?
Have you had a food allergy?
Have you had an allergy to a band-aid?
Have you had an allergy to a product used by the dentist?
Have you had an allergy to a product used during an X-ray examination?
Have you had an allergy to dust mites / pollen / mold / animals?
Have you had any allergies to anything else?
How does an allergy manifest itself?
Do you sometimes experience discomfort or pain in your chest, arm, or jaw when you exercise?
Do you sometimes experience discomfort or pain in your chest, arm, or jaw when you are resting?
Can you easily climb a flight of stairs without stopping for a breath problem?
Do you know how to clean the floor of your house?
If you have a garden, do you garden?
Do you do DIY?
(NB: golf, tennis, football, swimming, dance: >4METs)
Do you have heart palpitations during exercise?
Do you have heart palpitations at rest?
Do you get out of breath easily during light physical exertion?
Do you get easily out of breath at rest?
Do you experience fainting (loss of consciousness)?
Do you smoke ?
If you are interested in a tobacco consultation to help you quit smoking, do not hesitate to call 83 38 42/081, our colleagues will give you an appointment as soon as possible.
Do you have any "burn"?
Have you lost weight?
Was this weight loss intentional?
Have you changed your diet in the last week?
Reduction in the number of meals
Reducing the amount of food eaten at each meal
Do you snore loudly, several times a week, in the absence of any alcohol consumption?
- Are the snores interspersed with apneas with noisy breathing?
Do you wake up with a start several times a week and feel like you're suffocating?
Do you value your restful sleep?
(provided I slept in good conditions: quality/quantity)
Did you bleed for a long time after a tongue, lip, or cheek bite?
Have you experienced prolonged bleeding after a tooth extraction?
Did the bleeding start again after 24 hours, requiring a consultation for dental or medical treatment?
Have you experienced prolonged bleeding after minor operations such as adenoidectomy, tonsillectomy, appendectomy, circumcision, wound suturing?
Did the previous incidents occur to relatives or men on the maternal side?
Do you bruise easily without any apparent cause?
Have you ever seen a doctor to stop a nosebleed?
Have you had your nose stuffed by the ENT?
Do you regularly consume alcoholic beverages?
Do you tolerate anti-inflammatories?
Have you ever had any allergies or intolerances to certain medications?
Tablets and/or capsules?
Nasal Spray?
Injection?
Inhaler, puff or aerosol?
Patch (stuck to the skin)?
Cream or gel?
Liquid or syrup?
Suppository (rectal route) or ovule (vaginal route)?
Drops?
Magistral preparation (carried out by the pharmacy)?
Sample provided by your doctor?
THE NERVOUS SYSTEM (sleep, anxiety, depression, epilepsy, Alzheimer's or Parkinson's disease, etc.)?
DIGESTION (stomach acidity, nausea, vomiting, constipation, diarrhea, etc.)?
BREATHING: NOSE MOUTH THROAT LUNGS (asthma, bronchitis, cough, cold, etc.)?
THE HEART (hypertension, rhythm disorders, heart failure, etc.)?
BLOOD CIRCULATION (eg: Sintrom ®, Fraxiparine®, Clexane®, Pradaxa®, Xarelto®, etc.)
AGAINST PAIN AND/OR FEVER (e.g.: Aspirin®, Dafalgan®, Contramal®, codeine, morphine, etc.)?
DIABETES OR CHOLESTEROL?
BONES, MUSCLES OR JOINTS (rheumatism, osteoporosis, arthritis, gout, etc.)?
HORMONE-BASED (thyroid, birth control pill, menopause, etc.)?
GLUCOCORTICOID BASED (eg: Medrol®, Hydrocortisone®, etc.)?
SKIN (psoriasis, acne, eczema, warts, herpes, shingles, etc.)?
KIDNEYS, BLADDER, GENITAL ORGANS (incontinence, impotence, fertilization, etc.)?
EYES OR EARS?
ALLERGY?
AGAINST CANCER?
AGAINST ORGAN REJECTION?
A DEFICIENCY (vitamins, minerals, tonics, food supplements, etc.)?
In the last 3 months: Have you taken any medication for the infection?
Do you use drugs?
Add medications
R if Regularly or B if Needed
Example: Ledertrexate/tablet/2.5mg
Morning/noon/afternoon/evening/bedtime or Particular frequency taken in relation to meals
Add medication
R if Regularly or B if Needed
Example: Ledertrexate/tablet/2.5mg
Morning/noon/afternoon/evening/bedtime or Particular frequency taken in relation to meals