Bariatic request quote — BIMC Hospital Bali

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Have you been hospitalized, had surgery or received medical care? (please specify when and why)

NoYes[group group-have-you-been-hospitalized](if yes please specify)[/group]

Have you had any of the following Obesity surgeries; gastric sleeve; gastric bypass; or gastric banding before? (please explain)

NoYes[group group-have-you-had-any-of-the-following](if yes please specify)[/group]

Do you have implants or any metal objects in body?

NoYes[group group-do-you-have-implants](if yes please specify)[/group]

Have you ever taken an anticoagulant such as Coumading, Heparing, or daily aspirin? (when was your last dose?)

NoYes[group group-have-you-ever-taken-an-anticoagulant](if yes please specify)[/group]

Are you currently taking any medication (please list)

NoYes[group group-medication](if yes please specify)[/group]

Are you currently taking any vitamins or supplements (please list)

NoYes[group group-vitamins-or-supplements](if yes please specify)[/group]

Do you have difficulty healing or scarring?

NoYes[group group-difficulty-healing-or-scarring](if yes please specify)[/group]

Do you have any allegies to food, drugs, etc?

NoYes[group group-allegies-to-food ](if yes please specify)[/group]

Do you smoke? (how much)

NoYes[group group-do-you-smoke](if yes please specify)[/group]

Have you been diagnosed a mental illness? (provide details)

NoYes[group group-have-you-been-diagnosed](if yes please specify)[/group]

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Stop Bang Test *

Are you a male?

NoYes[group group-are-you-a-male](if yes please specify)[/group]

Are you a male with neck circumference greater than 17 inches, or a female with neck circumference greater than 16 inches?

NoYes[group group-circumference](if yes please specify)[/group]

Are you 50 years old or older?

NoYes[group group-are-you-50](if yes please specify)[/group]

Do you snore loudly?

NoYes[group group-do-you-snore](if yes please specify)[/group]

Do you feel tired, fatigued or sleepy during the day?

NoYes[group group-do-you-feel-tired](if yes please specify)[/group]

Have you been told you stop breathing during your sleep?

NoYes[group group-breathing](if yes please specify)[/group]

Do you have high blood pressure or are treated for high blood pressure?

NoYes[group group-pressure-or-are-treated](if yes please specify)[/group]

Is your body mass index greater than 35?

NoYes[group group-index-greater](if yes please specify)[/group]

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