Lapband Lap Band Surgery Qualification Form

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Fill out all * required fields below to see if you qualify for Lap-Band or Gastric Sleeve Surgery

Fill out Health History Questionnaire to see if you quality for Lap-band or Gastric Sleeve Surgery * Are Required

* Name

Male Female

*DOB

* Phone

	Marital status	Single Married Separated Divorced Widowed	*Weight	*Height	*Inches	*Enter BMI#

Previous or referring doctor

Date of last physical exam

Personal Heath History

Childhood illness

Measles Mumps Rubella Chickenpox Rheumatic Fever Polio

Immunizations and dates	Tetanus	Pneumonia
	Hepatitis	Chickenpox
	Influenza	MMR

	*List any medical problems that other doctors have diagnosed (If none type none).

Surgeries
Year	Reason	Hospital

Other hospitalizations
Year	Reason	Hospital

*Have you ever had a blood transfusion?

Yes No

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name the Drug	Strength	Frequency Taken

Allergies to medications
Name the Drug	Reaction You Had

* Health Habits And Personal Safety

Family Health History

* Mental Health

Women Only

Men Only

Other problems

I hereby give my permission to MyLapBandSurgery.Com too forward my information to the Bariatric Surgeon in Mexico.
I grant permission for my health history to be reviewed and verify to qualify for weight loss surgery.
The information I have provided is truthful to the best of my knowledge.

* I have read and accept disclaimer.

* Initials
I understand and agree by adding my initial that I have read the disclaimer and am in agreement with it.

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