Valoracion en linea

Información Pesonal

Gastric Sleeve Si

Adjustable Lap-Band Si

Intragastric Ballon / Orbera Si

Instragastric Ballon / Spatz 3 Si

Mini Gastric Bypass Si

Gastric Bypass Si

Revisional Surgery Si

Cirugía General Si

Interesado En

Yes

Si es Sí - Por Favor Especifique

Have had any previous weight loss procedures?

No Si

C-Section Si

Appendix Si

Gallbladder Si

Hiatal Hernia Si

Otro - Por Favor Especifique

Have had any previous open abdominal surgery?

No Si

Aspirin Si

Otro - Por Favor Especifique

Do you have any heart conditions?

No Si

Heartburn / Gerd Si

Gastritis Si

Colitis Si

Crohn's Disease Si

Diverticulitis Si

Ulcerative Colitis Si

Inflamatory Bowel Disease Si

Irritable Bowerl Syndrome Si

Otro - Por Favor Especifique

Do you have digestive disorders?

Nombre

Apellido

Edad

Género

Ocupación

Altura (Metros)

Altura (Centimetros)

Peso

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Dirección

Ciudad

Estado

País

Código Postal

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Antecedentes medicos

Información Pesonal

Interesado En

Have had any previous weight loss procedures?

Have had any previous open abdominal surgery?

Intake of Heart Medications

Do you have any heart conditions?

Do you have digestive disorders?