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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.


Input the correct text displayed in the image in order to submit your form.

 

 

 

 

 
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 TOLL FREE FROM USA 1-877-226-3453
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