Dr.Alejandro Aguirre Wallace
Ensenada , Mexico
PRE-SURGICAL MEDICAL QUESTIONNAIRE

 
    n  Please complete the attached medical questionnaire below. The information is necessary in the event your medication needs to be altered prior to surgery.  YOUR SAFETY DEPENDS UPON THE ACCURACY OF THE INFORMATION PROVIDED.  Your surgeon must be well-informed of your medical history. 
   
   
*Ref. Patient ID:     Patient Facilitator:
*Name(First):   (Middle): *Last:
*Address: *Phone Number(Home):   Work:
  Cell:   Date of  surgery: mm/dd/yyyy
  Sex:   Age:
City:   State: Zip:
*Date of Birth:  mm/dd/yyyy *Height:  feet  inches
Note: Enter numeric value 		*Weight:
*Email: *Highest Weight:   Year:
Name of Insurance Company: Address(Insurer):   Name of Insurer:
Date of Birth (Insurer):  mm/dd/yyyy Policy:  Group:
ID :        
 In case of emergency  
 		    
Contact person: *Emergency Phone#:

   
       

nMarital Status

Married
Unmarried Separated
       
   
             

n  Do you currently have Medical Insurance?
Yes
No
       
  If yes: Provider?

             

n  Is there a possibility that you could be pregnant?
Yes
No
       
  If Yes, please give details:

             

n  Are you able to walk one city block without assistance?
Yes
No
       
  If No, please give details:

             

n  Do you routinely use a cane, walker or wheelchair for assistance?
Yes
No
       
  If Yes, please give details:

             

n Have you ever been treated for cancer with chemotherapy or radiation therapy?
Yes
No
       
  If Yes, please give details:

             

n  Please check any of the following conditions that apply to your medical history:

           
   

  Head/Neck :

  Chronic sinus infections  
  Recurrent sore throat (more than 3 episodes/yr)  
  Thyroid disorder  
  Other  
                     
    Heart :                
  Diabetes (high sugars)  
  High blood pressure  
  Heart condition  
  Previous heart attack  
  Abnormal heart rhythm  
  Heart valve murmurs  
  High cholesterol,triglycerides(fats)  
  Other  
                     
    Lungs :                
  Asthma  
  Sleep apnea  
  Do you use BIPAP/CPAP machine?  
  Pulmonary embolism(blood clot in the lung)  
  Chronic bronchitis/emphysema  
  Have you ever been hospitalized for asthma or pneumonia?  
  Other  
                     
    Gastrointestinal :                
  Stomach ulcers  
  Acid reflux  
  Chronic constipation  
  Chronic diarrhea  
  Blood in stool or vomiting blood  
  Liver cirrhosis  
  Hepatitis  
  Other  
                     
    Blood :                
  Lukemia/limphoma  
  Prolonged bleeding  
  Anemia  
  Other  
                     
    Kidneys and Urinary Tract :                
  Kidney disease/failure  
  Recurrent urinary tract infections  
  Kidney or bladder stones  
  Other  
                     
    Circulation :                

      Do you have chronic legs ?
Yes
No
       
 
  Right leg
 
 
 
  Left leg
 
 
 
  Both legs
 
 

      Have you ever been       diagnosed with a blood       clot(deep vain       thrombosis- DVT)?
Yes
No
       
  Other  
                     
    Muscles/Bones :                
  Joint pain/arthritis
Yes
No
 
  Hips
 
 
 
  Knees
 
 
 
  Ankles
 
 
 
  Lower back
 
 
  Other  
                     
    Neurological :                
  History of seizures
Yes
No
  Date of last seizure   mm/dd/yyyy
  History of stroke
Yes
No
  Date of stroke   mm/dd/yyyy
  Other  
                     
    Psychiatric :                
  Have you ever been under the care of a psychiatist ?
Yes
No
  Have you been diagnosed with :    
 
  Anxiety disorder
 
 
 
  Major depression
 
 
 
  Bipolar disorder
 
 
 
  Schizophrenia
 
 
  I have had suicidal thoughts in the last 5 years
Yes
No
  Other  
                     
    Cancer :                
  Cancer type  
 
  Chemotherapy
 
 
 
  Radiation
 
 
  Other  
                     

Surgical History
Please list any previous surgeries you have had, along with the date:

            

           

 

            

n Have you had an adverse reaction to anesthesia?
Yes
No
       
  If Yes, please indicate the reaction:

 

            

n Are you scheduled for any other upcoming operations?
Yes
No
       
  If Yes, what operation and when?

 

            

Medications

            

n Are you currently taking any medication or herbal supplements?

Yes
No
       

 If yes,please provide the name, dosage and reason:

           
           
                     

The following medications are extremely important for your surgeon to know if you are taking.  Please check all that apply.

            
    Aspirin (Excedrin, Bufferin)              
  Dosage and how often  
  Ibuprofen (Motrin, Advil)  
  Dosage and how often  
  Blood thinners (Coumadin,Plavix, Heparin)  
  Dosage and how often  
  Digitalis (heart pills)  
  Dosage and how often  
  Steroids (prednisone, cortisone)  
    Dosage and how often              
                     

Allergies

            

nAre you allergic to any medication or food?
Yes
No
       
  If Yes, please list drug allergies:

 

            

nAre you allergic to Latex?
Yes
No
       

 

            

Lifestyle

            

n Do you smoke cigarettes?
Yes
No
       
  If Yes, how much?  

 

            

n Do you drink alcohol?
Yes
No
       
  If Yes, how much?  

 

            

n Do you take recreational drugs?
Yes
No
       
  If Yes, what kind and how often?  

 

            

Please Note:  There have been very few cases of anyone sent home without the lap band surgery;
however, all precautions are taken to ensure your health.

There also exists a possibility that once you arrive and have your complete physical, the Doctors may find something in your tests that would prevent you from having the surgery at that time.  The Doctors always have your best interest in mind and will not proceed if there is any added risk.  These precautions are for your safety and long-term band health.

Your signature acknowledges all information provided is correct to the best of your ability.