PERSONAL INFORMATION
First Name: Middle Name:
Last Name: Additional Surname:
Gender:
Date of birth:
Marital Status:
Address:
Country:
City:
Telephone:
Mobile:
Office phone:
Email:
How did you know about OBESITY EL SALVADOR?:

Ocupation:
Your Hobbies:
Children:
Height and Weight:
Height: Feet Inches
Current Weight: Pounds
WEIGHT HISTORY
Weight 3 months ago: Pounds.
Weight 1 year ago: Pounds.
Highest weight over the last 5 years: Pounds.
Lowest weight over the last 5 years: Pounds.
Have you tried to lose weight?:
have you regained the lost weight?:
Have you been supported by a nutritionist or other health professional?:
FAMILY HISTORY
Obese relatives:
Relatives with diabetes:
Relatives with hypertension:
Relatives with high cholesterol or triglycerides:
Deaths in family by heart attack or stroke:
PERSONAL HISTORY
Presence of other diseases on you. If the answer is yes, please describe the treatment you're receiving. By telling us the name and dosage of medications, it will help our physicians on taking the best decision for your case.
Diabetes:
Hypertension:
Fat or High Cholesterol:
Joint problems:
Do you snore a lot?:
Do you fall asleep easily in a waiting room or watching TV?:
Respiratory problems:
Heart problems:
Other problems or diseases:
Previous surgeries:
Known allergies to medications:
Current or former psychological-psychiatric problems:
Do you drink alcohol?
Do you smoke?:
Do you use other drugs?:
DIET AND EXERCISE
Do you consider yourself a person who eats large amounts of food?:
Do you think you gain weight easily?:
What are the four most common types of food you eat?:
Are you addicted to candies and/or chocolates?:
Daily exercise:
Which is the procedure you prefer?:
Extra information: