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Gastric Banding Form

Personal and Medical form

Lap band surgery
 
Surname * :  
Forename * :  
Date of birth * :  
Profession :  
Adress :  
City :  
Post code/ Zip code :  
Country :  
Nearest airoport :  
Home phone :  
Work phone :  
Mobile phone :  
If you accept to be contacted
by one of our team members
preferred contact time :		   Monday to Friday at 8h30 to 16h30
Fax :  
E-mail * :  
Procedure
How do you intend to send us your photos :  
Hotel :  
Arrangement :  
Type of room :  
Number of adults :  
Number of children (5 to 12) :  
Number of children (less than5) :  
When will you consider travelling to Tunisia ? :  
Excursion/Leisure (not included in the package) :  
Comments :  
Personal information
Your size :  
Your height * :  
Your current weight * :  
What is the maximum weight you have reached ? :  
Your Thighs size * :  
Your Waist size * :  
Do you smoke ? :   Yes  No
If yes, how many cigarettes a day ? :  
When did you start smoking ? :  
Have you stopped smoking ? :   Yes No
Since when ? :  
Do you drink alcohol ? :   Yes No
How often ? :  
Are you taking any particular substance (drugs,.) ? :   Yes No
If yes, please specify which ones ? :  
At what frequency ? :  
State of Obesity
How long are you suffering from obesity ? :  
What are the various methods used to reduce your
weight ? :		  
What were the results ? :  
Who suggested the gastric band to you ? :  
Medical history
Yes / No
Are you taking
any treatmnt ?
Do you have or have you ever had any of the following :
Cardiac condition ? :   Yes No Yes No
Give details and dates as appropriate :  
High blood pressure ? :   Yes No Yes No
Give details and dates as appropriate :  
Blood clots in legs (Blood thrombosis) ? :   Yes No Yes No
Give details and dates as appropriate :  
Lung disease (asthma or breathing problems) ? :   Yes No Yes No
Give details and dates as appropriate :  
Diabetes ? :   Yes No Yes No
Give details and dates as appropriate :  
Raised Cholesterol level ? :   Yes No Yes No
Give details and dates as appropriate :  
Do you suffer from Triglyceride (hypertriglyceridemia) ? :   Yes No Yes No
Give details and dates as appropriate :  
Thyroid desease ? :   Yes No Yes No
Give details and dates as appropriate :  
Digestive problems ? :   Yes No Yes No
Give details and dates as appropriate :  
Oesophagi’s (oesophagus infection) ? :   Yes No Yes No
Give details and dates as appropriate :  
Gastric or duodenal ulcer ? :   Yes No Yes No
Give details and dates as appropriate :  
Hiatus (part of stomach sliding up into  thorax) ? :   Yes No Yes No
Give details and dates as appropriate :  
Oesophagus or gastric varicose ?   Yes No Yes No
Give details and dates as appropriate :  
Cirrhosis ? :   Yes No Yes No
Give details and dates as appropriate :  
Digestive bleeding ? :   Yes No Yes No
Give details and dates as appropriate :  
Cavities or any dentistry infections ? :   Yes No Yes No
Give details and dates as appropriate :  
Any infection ? :   Yes No Yes No
Give details and dates as appropriate :  
Any systemic pathology (exp: Systemic erythematic lupus, Scleroderma …) ? :   Yes No Yes No
Give details and dates as appropriate :  
Other pathologies ? :   Yes No Yes No
Give details and dates as appropriate :  
Surgeries History
Did you undergo surgeries before ? :   Yes No
Surgery 1 :  
When ? :  
Open surgery (laparotomy) ? :   Yes No
Celioscopy (laparoscopy) ? :   Yes No
Surgery 2 :  
When ? :  
Open surgery (laparotomy) ? :   Yes No
Celioscopy (laparoscopy) ? :   Yes No
Allergy
Do you suffer from any allergy including allergies to medicines ? :   Yes No
If yes, please list allergies including allergies to medicines :  
Have you ever had a reaction to any medication or drug; local anaesthetic; or general anaesthetic ? :   Yes No
If yes, please list medication and type of reaction :  
Gynaecological and obstetric records
Have you ever had children ? :   Yes No
If yes, How many :  
Have you ever had caesareans ? :   Yes No
If yes, how many times :  
Are you pregnant ? :   Yes No
If yes, please indicate how far along :  
Do you intend becoming pregnant ? :   Yes No
If yes, please specify the date of your last Menstruation :  
Psychological State
Are you taking any treatmnt ?
Do you have or have you ever had psychiatric problems, depression or other psychological trouble ? :   Yes No Yes No
Important : If yes, give details and dates as appropriate :  
Since when have you been convinced of the chosen procedure ?
Important : If yes, give details and dates as appropriate :  
Medical Treatments
Are you now or have you ever taken any medication regularly either prescribed or bought over the counter (containing aspirin, anticoagulant pills, birth control pills, ect) ?   Yes No
Important : If yes, please list the medicines :
Currently taken :  
Previously taken :  
Fields marked with an asterisk * are required.
 

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