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Direct Line:
Skype:

1(877) 789-5272
(559) 723-6484
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Patient questionnaire

THE INFORMATION SUBMITTED BY YOU IS PRIVILEGED AND CONFIDENTIAL

Title:	First Name:	Middle Name:	Last Name:
	*
	Email:		Age:
	*
	Address:

	Phone number:

	Time when one of our representativess can contact you:

	Occupation:

Allergies:

Any previous surgeries:

Hospitalizations:

Obesity related problems:
Physical:

Sleep disorders:

Bone problems:

Physical condition:

Digestive system:

Heart and circulatory system:

Obesity related problems: (Emotional)
Compulsive eating:

Mild Depression:

Low expectations:

Isolation:

Other:

Eating habits: (History)
Brakfast food and Time:

Brunch food and Time:

Lunch food and Time:

Dinner food and Time:

Favorite Foods:

Foods that you dont like:

Foods that you do not tolerate or are allergic to?:

What kind of diets have you carried out (specify the number and results of each one)?:

Why did you decide to try our treatmet for obesity?:

How did you find about us?: Please, provide us with this information so we can enhance our services.


Patient Liaison

		Socorro Mercado Toll free number: (877) 789-5272 Direct line: (559) 723-6484 Hablo Español

Available 24/7 for your convenience

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