Medical Questionnaire Metric Imperial Gender Male Female Country AfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBrazilBrunei DarussalamBulgariaBurkina FasoBurma/MyanmarBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongoCosta RicaCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominican RepublicDominicaEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench GuianaGabonGambiaGeorgiaGermanyGhanaGreat BritainGreeceGrenadaGuadeloupeGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKosovoKuwaitKyrgyz RepublicLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgRepublic of MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotteMexicoMoldovaRepublic of MonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorwayOmanPacific IslandsPakistanPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent's & GrenadinesSamoaSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandTimor LesteTogoTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsUgandaUkraineUnited Arab EmiratesUnited States of America (USA)UruguayUzbekistanVenezuelaVietnamVirgin Islands (UK)Virgin Islands (US)YemenZambiaZimbabwe Next Choose your surgery* Select Surgery Gastric SleeveEndoscopic Gastric SleeveGastric BalloonGastric Bypass one anastomosisBypass en Y de Roux Prev Next Do you have a chronic desease* Yes No Write down the medicines you currently take* Do you have allergies?* Yes No Have you ever had surgeries?* Yes No Do you suffer from gastroesophageal reflux symptoms such as heartburn or regurgitation?* Yes No Prev Next If your have any questions or comments it's important that you let us now. Social media Submit
