First Name(Required)Last Name(Required)DOB (MM/DD/YEAR)(Required) MM slash DD slash YYYY Phone(Required)Health Card(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Height (Feet and Inches)(Required)Weight (LBs)(Required)What Type of Surgery Are Your Looking For?(Required)Medical HistoryHigh blood pressure:(Required) Yes No What was your most recent blood pressure (BP) reading?Heart attack, angina, rhythm problems:(Required) Yes No Please describe(Required)Asthma or lung disease:(Required) Yes No Please describe(Required)Anxiety or depression:(Required) Yes No Please describe(Required)Special needs (i.e. Autism or mobility issues) Yes No Please describeMental health disorder:(Required) Yes No Please describeLiver disease, hepatitis, or HIV:(Required) Yes No Please describe(Required)Kidney disease:(Required) Yes No Please describe(Required)Diabetes:(Required) Yes No Which Type?(Required) Type 1 Type 2 Thyroid disease:(Required) Yes No Please describe(Required)Epilepsy, stroke or nervous system disease:(Required) Yes No Please describe(Required)Heartburn, ulcers, hiatus hernia:(Required) Yes No Please describe(Required)Diagnosed with antibiotic resistant organism (MRSA, VRE, ESBL)(Required) Yes No Please describe(Required)Chronic Pain:(Required) Yes No Please describe(Required)Problems with anesthesia:(Required) Yes No Please describe(Required)Family problems with anesthesia:(Required) Yes No Please describe(Required)Do you have any allergies?(Required) Yes No What are you allergic to, and what is the reaction?(Required)Other major health issue not stated previously?(Required) Yes No Please describe(Required)Substance UseDo you currently smoke?(Required) Yes No How much daily?(Required)Do you drink alcohol?(Required) Yes No how many drinks/week?(Required)OtherDo you wear contact lenses or have any medical devices (ie: hearing aids)(Required) Yes No Which devices?(Required) Contact Lenses Hearing Aids Pacemaker Other Please List Other(Required)Would you accept the use of blood or blood products if it were necessary to save your life?(Required) Yes No SleepDo you snore loudly? (enough to be heard through a closed door)(Required) Yes No Do you often feel tired, fatigued, or sleepy during the day?(Required) Yes No Has anyone noticed that you stop breathing in your sleep?(Required) Yes No Have you been tested for sleep apnea?(Required) Yes No Please describe: Negative, Mild, Moderate, Severe(Required)Was a CPAP machine recommended?(Required) Yes No When was it recommended?Do you currently use a CPAP machine?(Required) Yes No MedicationsDo you take any prescriptions, over the counter medications regularly, vitamins, minerals, supplements?(Required) Yes No List prescriptions, over the counter medications taken regularly, vitamins, minerals, supplements:(Required)Have you taken any of the following medications within the last month. (Check all that apply) Mounjaro Yes Saxenda Yes Ozempic Yes Victoza Yes Tulicity Yes Wegovy Yes None of these I haven’t taken any of these listed medications SurgeriesHave you had any surgeries in the past?(Required) Yes No Please list all surgeries you’ve had and approximate year:(Required)
