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HEALTH QUESTIONNAIRE

* The information you provide will help us to propose the best treatment for you, for which we ask you to respond with care and sincerity.

IDENTIFICATION FILE

PERSONAL HISTORY

Have you been diagnosed with hepatitis?

Are you allergic to latex?

Allergic to any medicine or food?

MEDICATIONS CURRENTLY USED

DISEASES THAT SUFFERS

SURGERY THAT HAVE BEEN MADE

Have you had any surgery for weight control?

Have you suffered a heart attack?

DIGESTIVE

Have you been diagnosed with diverticulitis?

Do you have a history of ulcers?

Have you been diagnosed with ulcerative colitis?

Do you suffer from indigestion or reflux?

DIABETIC HISTORY

Indicate any additional information that you think is important in the evaluation of your health status

I understand that it is important to give complete and true information for my own safety; so I have filled out this questionnaire with all the information I know, and I have answered with complete sincerity for my own health and safety.

United Medical Credit

If utilizing United Medical Credit to finance a procedure, a service fee of 10% will be added to the price of the surgery.

Questionnaire