Medical questionnaire

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

First name: *

Surname: *

Sex: *

Male

Female

Address: *

Telephone: *

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

Email: *

Occupation:

Date of Birth: *

Your height: * cm

Your weight: * kg

Your maximal weight during the last 5 years: kg

BMI: (please skip this field, it calculates automatically)

How long are you dealing with obesity?:

Next of Kin

Full name: *

Address: *

Telephone: *

Your General Practitioner (GP)

We will contact your GP only with your permission.

Full name: *

Address: *

Telephone: *

Waist circumference: cm

Hip circumference: cm

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Medical questionnaire