Bariatic request quote — BIMC Hospital Bali
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    Please fill out this initial assessment form so that we can work on the detail quote for you
    Any medical conditions? *
    NoYes[group group-anesthesia-problems ][/group]
    NoYes[group group-blood-disorders][/group]
    NoYes[group group-blood-pressure-problems][/group]
    NoYes[group group-diabetes-or-blood-sugar-problems][/group]
    NoYes[group group-heart-problems][/group]
    NoYes[group group-kidney-or-liver-problems][/group]
    NoYes[group group-lung-problems][/group]
    NoYes[group group-neurological-problems][/group]
    NoYes[group group-nervous-breakdown][/group]
    NoYes[group group-previous-current-history][/group]
    NoYes[group group-thyroid-problems][/group]
    NoYes[group group-other][/group]
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    NoYes[group group-have-you-been-hospitalized][/group]
    NoYes[group group-have-you-had-any-of-the-following][/group]
    NoYes[group group-do-you-have-implants][/group]
    NoYes[group group-have-you-ever-taken-an-anticoagulant][/group]
    NoYes[group group-medication][/group]
    NoYes[group group-vitamins-or-supplements][/group]
    NoYes[group group-difficulty-healing-or-scarring][/group]
    NoYes[group group-allegies-to-food ][/group]
    NoYes[group group-do-you-smoke][/group]
    NoYes[group group-have-you-been-diagnosed][/group]
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    Stop Bang Test *
    NoYes[group group-are-you-a-male][/group]
    NoYes[group group-circumference][/group]
    NoYes[group group-are-you-50][/group]
    NoYes[group group-do-you-snore][/group]
    NoYes[group group-do-you-feel-tired][/group]
    NoYes[group group-breathing][/group]
    NoYes[group group-pressure-or-are-treated][/group]
    NoYes[group group-index-greater][/group]
    [cf7mls_step step-3 "Next" ""]

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