Help With Obesity Tijuana, Mexico, Patient questionnaire ,Gastric Sleeve

Use this link to send me Files: Video's, graphics, images, and more

If you're ready to begin the process, this is a great place to start. There's no obligation - The information submitted by you is privileged and confidential,Bajanor Obesity Center does not distribute or sell this information to 3rd parties,as it is used strictly for medical evaluation. Simply fill out the form below, and we'll contact you as soon as possible.

Patient Questionnaire

	Title:

	Name :

	Age:

	Address:

	Phone Number :

Time where one of our representatives can contact you:

	Ocupation:

	email:

	Height:
	' "

	Weight: (lb)

	Waist:(in)

	BMI:

	At what age did obesity become evident?:
	years

	Allergies:

	Any previous surgeries:

	Hospitalizations:

Obesity related problems:

	Physical:

	Sleep disorders:

	Bone problems:

	Physical condition:

	Digestive system:

	Heart and and circulatory system:

Obesity related problems: (Emotional)

	Compulsive eating:

	Mild Depression:

	Low expectations:

	Isolation:

	Other:

Eating habits: (History)

	Brakfast food and Time:

	Brunch food and Time:

	Lunch food and Time:

	Dinner food and Time:

	Favorite Foods:

	Foods that you dont like:

	Foods that you do not tolerate or are allergic to?:

	What kind of diets have you carried out (specify the number and results of each one)?:

	Why did you decide to try our treatmet for obesity?:

	How did you find about us?: Please, provide us with this information so we can enhance our services.

Image Verification

Please enter the text from the image
[ What's This? ]

Calle Ferrocarril No 10634 Col. Libertad Parte Baja C.P. 22300, Tijuana, B.C. México.
Tels: 682 -3005 , 682-3008 USA: 01152- 664-6823005 or Direct Line Usa : 619-739-4234
TOLL FREE FROM USA 1-888-294-0342,1-877-226-3453
© Copyright Obesity Center 2007

Please enter the text from the image [ What's This? ]

Please enter the text from the image
[ What's This? ]