Contact Information
First Name:
Last Name:
Email:
Phone:
+1 (USA)
+1 (CAN)
+52 (MEX)
Personal Information
Age:
Sex:
Male
Female
Prefer not to say
Height:
150 cm (4'11)
152 cm (5'0)
155 cm (5'1)
157 cm (5'2)
160 cm (5'3)
163 cm (5'4)
165 cm (5'5)
168 cm (5'6)
170 cm (5'7)
173 cm (5'8)
175 cm (5'9)
178 cm (5'10)
180 cm (5'11)
183 cm (6'0)
185 cm (6'1)
Weight:
Under 68 kg (Under 150 lbs)
68-91 kg (150-200 lbs)
91-113 kg (201-250 lbs)
113-136 kg (251-300 lbs)
136-159 kg (301-350 lbs)
Over 159 kg (Over 350 lbs)
Medical Record
Do you smoke?
Yes
No
Sometimes
How frequent do you drink?
I don't drink
1 to 3 drinks / week
3 to 5 drinks / week
More than 5 drinks / week
Do you use any kind of drugs? (Excluding marijuana)
No
Yes
How frequent do you exercise?
Active
Sometimes
Almost never
Other Health Information:
Interest
Procedures of Interest:
Gastric Sleeve
Mini gastric sleeve
Gastric Bypass
Bariatric revisional Surgery
Sadi
Other
Message:
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