Medical questionnaire

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  • strict warning: Only variables should be assigned by reference in /users/zalohovane/cierny.cz/bandazzaludka.sk/modules/texy/texy.module on line 208.
  • strict warning: Only variables should be assigned by reference in /users/zalohovane/cierny.cz/bandazzaludka.sk/modules/texy/texy.module on line 208.

This questionnaire on your health status helps to asess whether you are a good candidate for bariatric surgery. It has 3 parts, and it takes about 30 minutes to enter the complete form. The information will be saved only if you fill and submit the entire form.

We understand and respect that the information you submit are confidential.

Personal information

Please use international telephone format, e.g. +420 123–456–789 (with +XYZ as your country prefix).

cm
kg
kg
(please skip this field, it calculates automatically)
Next of Kin
Your General Practitioner (GP)

We will contact your GP only with your permission.

cm
cm

Vypľnte dotazník a zjistite či Vám operácia može pomôcť.