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BIMC Siloam Nusa Dua
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About Bariatric Surgery /
Request Your Quote
Full Name
Email Address
Please fill out this initial assessment form so that we can work on the detail quote for you
Any medical conditions? *
Anesthesia problems
No
Yes
(if yes please specify)
Blood disorders
No
Yes
(if yes please specify)
Blood pressure problems
No
Yes
(if yes please specify)
Diabetes or blood sugar problems
No
Yes
(if yes please specify)
Heart problems
No
Yes
(if yes please specify)
Kidney or liver problems
No
Yes
(if yes please specify)
Lung problems
No
Yes
(if yes please specify)
Neurological problems
No
Yes
(if yes please specify)
Nervous breakdown/ depression
No
Yes
(if yes please specify)
Previous/ current history of cancer
No
Yes
(if yes please specify)
Thyroid problems
No
Yes
(if yes please specify)
other
No
Yes
(if yes please specify)
Next
Have you been hospitalized, had surgery or received medical care? (please specify when and why)
No
Yes
(if yes please specify)
Have you had any of the following Obesity surgeries; gastric sleeve; gastric bypass; or gastric banding before? (please explain)
No
Yes
(if yes please specify)
Do you have implants or any metal objects in body?
No
Yes
(if yes please specify)
Have you ever taken an anticoagulant such as Coumading, Heparing, or daily aspirin? (when was your last dose?)
No
Yes
(if yes please specify)
Are you currently taking any medication (please list)
No
Yes
(if yes please specify)
Are you currently taking any vitamins or supplements (please list)
No
Yes
(if yes please specify)
Do you have difficulty healing or scarring?
No
Yes
(if yes please specify)
Do you have any allegies to food, drugs, etc?
No
Yes
(if yes please specify)
Do you smoke? (how much)
No
Yes
(if yes please specify)
Have you been diagnosed a mental illness? (provide details)
No
Yes
(if yes please specify)
[cf7mls_step step-2 "Next" "]"]
Stop Bang Test *
Are you a male?
No
Yes
(if yes please specify)
Are you a male with neck circumference greater than 17 inches, or a female with neck circumference greater than 16 inches?
No
Yes
(if yes please specify)
Are you 50 years old or older?
No
Yes
(if yes please specify)
Do you snore loudly?
No
Yes
(if yes please specify)
Do you feel tired, fatigued or sleepy during the day?
No
Yes
(if yes please specify)
Have you been told you stop breathing during your sleep?
No
Yes
(if yes please specify)
Do you have high blood pressure or are treated for high blood pressure?
No
Yes
(if yes please specify)
Is your body mass index greater than 35?
No
Yes
(if yes please specify)
Next
Δ
About Bariatric Surgery
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