Appointment

 


Name: Age:

Address:

Telephone - Days: Evenings:

Email:

Insurance Carrier:

Height: Weight:

Number of years severely overweight:

Weight Loss Methods Tried:
Weight Watchers Phen/Fen
Jenny Craig Richard Simmons
Opti Fast Calorie counting
Nutri System Physician supervised program
Slim Fast Dietician supervised program
Ultra Slim Fast Dexatrim
Redux Metabalife

List any other diet pills not listed above:

List any other diet method not listed above:
Do You Have Any Of The Following Conditions?
Asthma Sleep apnea or other respiratory problems
Hypertension History of stomach ulcers
Diabetes History of upset stomach or pain
Joint pain Allergies (If yes, allergic to what?
Arthritis (If yes, where?):
 Severe gastro esophageal reflux
Low back pain Pickwickian syndrome
Fluid retention
(swelling of the hands and/or feet)		 Elevated lipid level or cholesterol level
Shortness of breath when climbing stairs Recurrent hernias
Heart problems (If yes, what?):
 Gallbladder disease
Chronic depression as a result of obesity Chronic phlebitis and/or venous insufficiencies
Do Any Of Your Relatives Have Any Of The Following?
Diabetes History of being overweight
Have You Ever Had Any Of These Surgeries Before?
Gallbladder removed Tonsils removed
Uterus/ovaries removed Back surgery
Joint surgery (If yes, what type?)
 Appendix removed
Heart surgery Lung surgery
Previous weight loss surgery (If yes, what type?):
 Any surgery not mentioned (If yes, what type?)
Click on the image below to fill out an extended patient form that you may either submit online or bring in to our office on your first visit!
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Additional Comments Or Questions


Baltimore Bariatrics
1001 Cromwell Bridge Rd.
Towson. MD 21286 | (410) 583-0123
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