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Bariatric/Obesity Surgery Enquiry
Thank you for choosing mymeditrip to assist you towords your improved health and healthier tommarow.
We request you to please fill the details completly as this would help your selected surgeon to do correct clinical evaluation and revert back with proposed line of treatment.
Please Note: For this enquiry to reach us you must provide a valid email address.
Name:
Mailing Address:
Gender:
Martial Status :
Age:
Height in cms:
Weight in Kgs:
BMI:
City:
State:
Country:
Telephone:
E-mail:
Please indicate your weight at the following times. Please indicate whether you consider your weight was below average, average, above average or very heavy in the relevant boxes.
Weight at beginning of high school:
Weight at commencing work (21 years):
Weight at time of marriage (if applicable):
Age when you first remember overweight:
Age when you first began dieting:
At what weight have you felt your best:
Dieting History:
Diet Program if any and the result:
Food History
Preferred foods (foods most likely to make you go off a diet)
(Rank each selection from 1- like very much to 4-Don't care )
Soda / Soft Drinks:
1
2
3
4
Chips / Snacks:
1
2
3
4
Potatoes
1
2
3
4
Cookies:
1
2
3
4
Pasta
1
2
3
4
Candy
1
2
3
4
Pizza:
1
2
3
4
French Fries:
1
2
3
4
Steaks / Chops:
1
2
3
4
Cakes / Pies:
1
2
3
4
Chocolate
1
2
3
4
Others (Specify):
1
2
3
4
Salad Dressings:
1
2
3
4
Fried Foods:
1
2
3
4
Favorite Foods:
How do you decide when to stop eating?
Food Allergies (if any):
Do you drink juices, sweet tea, sweets or regular sodas:
Do you understand the long-term changes in food intake that will be necessary after surgery for the rest of your life? :
How many meals you eat in a day:
Do you eat between meals:
Do you drink for reasons other than hunger or thirst:
Do you drink milk:
Do you drink water
How much a Day?:
Do you eat sweets
If yes How often:
Do you understand the long term changes in food intake that will be necessary after surgery for the rest of your life:
Do you understand the consequences of not complying with post op food guidelines:
How many meals you eat in a day
Do you eat between meals:
How fast do you eat:
WEIGHT RELATED ILLNESS
Have you had, or do you have, any of the following illnesses or symptoms?
Heart Disease:
High Blood Pressure:
Do you have or ever had any of the following illness - If Yes Year Diagnosed
Angina:
M.I(myocardial infarction):
CABG(coronary artery bypass graft):
High Cholesterol:
Medication list:
Diabetes:
Neuropathy:
Abnormal EKG:
Stress test to rule out cardiac problems:
High Triglycerides:
Asthma:
Trouble sleeping:
Shortness of Breath:
Last fasting blood sugar:
Morning Headaches:
Daytime drowsiness:
Restless Sleep:
Snoring:
Awakening at night:
Observed apneas:
Sleep apnea syndrome:
Last sleep study, CPAP used:
Heartburn/hiatus Hernia:
Hepatitis:
Blood Transfusion:
AIDS/HIV exposure:
Colitis:
Kidney Disease:
Bleeding Abnormality:
Thyroid problems:
Gall bladder disease:
Low back strain/pain/sciatica:
Pain in hips/knees/ankles/feet:
Leakage of urine with laughing/coughing/sneezing:
Leg ulcers, scaly & thick skin if yes do you have Edema:
Only Female patients:
Are you pregnant now:
Number of pregnancies:
Number of live births:
Obstetric complications:
Age at first period:
Date of last period:
Miscarriages/Abortion:
Please list below all serious and hospitalization you have experienced in adulthood: Major Illness /Surgery Date and Treatment. If Yes, Please list medication and reaction.:
SOCIAL HISTORY
Do you use tobacco currently
If yes, how many packs/day:
How many years have you smoked:
Have you tried to quit:
Did you smoke in the past:
How many packs/day:
When did you quit:
Do you drink beer,liquor,or wine:
How many glasses per week:
Do you use any recreational drugs:
Which one(s):
Have you ever had an addiction to drugs:
Who usually prepares the food you eat at home:
ACTIVITY LEVEL & SOCIAL INFO
What exercise do you do on regular basis:
How many sessions of exercise (walking,sports,etc)do you do per week for more than 30 minutes at a time:
EDUCATION
Highest level of course pursued:
Please list your activities (out of home):
Please list major personal interests:
How would you describe your current weight:
How does your weight affect you in daily activities:
How does your weight affect you socially:
Why do you want to lose weight:
Why are you considering surgery to help you lose weight:
How much weight would you like to lose:
Highest acceptable weight:
Desired lowest weight:
How does your family feel about you having this surgery:
What are your concerns about your health:
What are your concerns or fears about the surgery:
What surgical procedure are you currently interested in:
PATIENT COMMITMENT
IF YOU ARE ACCEPTED FOR SURGERY, THE FOLLOWING ARE VERY IMPORTANT TO MAINTAIN GOOD HEALTH AND TO ACHIEVE THE DESIRED WEIGHT LOSS.
Are you willing to avoid foods and beverages containing sugar:
Are you willing to never use tobacco products:
Please Confirm
Alcohol causes gastric irritation and liver damage. After surgery, frequent alcohol consumption is unwise and can be harmful. Are you willing to have no alcohol for at least one year after surgery, and to use alcohol only on a very limited basis thereafter
Please Confirm
Are you willing to make a commitment for regular lifelong medical follow-up:
Would you like to Add Tour?
Yes
No
Best of Himachal 7N/8D
Golden Triangle Tour 4N/5D
Best of Uttaranchal 4N/5D
Best of Darjeeling 7N/8D
Best of Karnataka 6N/7D
Best of Kashmir 5N/6D
Hills & Backwaters of Kerala 5N/6D
Grand Kerala 7N/8D
Vaishno Devi Tour 2N/3D
Tirupati Balaji Darshan 2N/3D
Sikh Pilgrimage Tour 4N/5D
Shirdi Sai Darshan 2N/3D
Best of Rajasthan 8N/9D
Glimpses of Rajasthan 5N/6D
Tiger Land Safari 7N/8D
Taj and Tiger Tours 15N/16D
Ayurveda & Yoga 8N/9D
Majorda Beach Resort
Whispering Palms Beach Hotel (Continental Package)
Whispering Palms Beach Hotel (Economic Map Package)
Whispering Palms Beach Hotel (Premium American Plan)
Whispering Palms Beach Hotel (All Inclusive Luxury Package)
Victor Exotica Beach Resort (Winter Packages)
Toshali Sands (Dreams Package)
Toshali Sands (Discovery Packages - 3N/4D)
Toshali Sands (Sun and Sea Packages - 4N/5D)
Anandas Packages
Ananda Wellness Bliss
Ananda Ayurvedic Rejuvenation
Ananda Stress Management
Ananda Himalayan Romance
Ananda Detox
Ananda Weight Management
Ananda Yoga
Ananda Tranquility
Ananda Fitness
Ananda Anti Ageing Programme
Carmelia Haven
Kairali Ayurvedic Health Resort(Ayurveda Package )
Kairali's Special Treatment For Arthritis & Spondylitis
Ayurveda Panchakarma & Rasayana Package
IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW
Terms & Conditions
--------------------------------------------------------------------
Cost Estimate:
--------------------------------------
The cost estimate for recuperation is quoted in Indian Rupees subject to exchange rate fluctuations. Certain terms and Conditions apply.
Any bookings confirmed and not taken up will be subject to cancellation fees.
Includes:
--------------------------------------
Accommodation
Personal Assistant to accompany you to all your medical appointments and surgery
Transport for return airport transfers and medical appointments.
Detailed Itinerary.
Excludes:
--------------------------------------
Tour Options.
Transport for all additional outings
Rejuvenation treatment.
.Additional expenses not specified.
Meals
Payment Terms:
--------------------------------------
Non-Refundable Deposit required securing your booking.
Deposit to be invoiced and paid to MyMediTrip via bank Transfer - as indicated on the invoice - and will be deducted from the daily room rate charged.
Balance payable when you check in on arrival.
Payment can be made via valid Credit Card or Travelers Cheque or Cash.
--------------------------------------
Surgery - Terms and Conditions
--------------------------------------
Medical Evaluation:
--------------------------------------
The fee quoted will be confirmed after further medical evaluation by the surgeon.
We will arrange for Initial Clinical Evaluation by the surgeon after receiving the Medical History Form and recent Photographs /X-Ray's / CT scan / MRI Scan's / Echocardiogram / Angiogram / Pathological Reports or a summary of observations on them as per the treatment/ procedure requirements
We encourage you to ask questions using email or the telephone.
Both you and the surgeon are under no obligation until after your pre operative consultation.
MyMediTrip reminds you that all surgeries carry risks, have limitations which could include disappointment with the results.
You should agree about the anticipated outcome of your surgery and concur about your expectations of the results.
You should discuss alternative treatments and thoroughly understand the risk of the procedures
If any dispute may arise the surgeon is only liable if litigation takes place in India under Indian Law.
Any medical or surgical advice provided through the MyMediTrip web site and service, even if intended to be accurate to the best of our knowledge, should be discussed with the Surgeon.
Always seek advice from your Surgeon before embarking on any treatment, medication or therapy.
Cost Estimate - Surgery:
--------------------------------------
The cost estimate is to be confirmed by the surgeon at your pre-op consultation prior to surgery.
The cost estimate is subject to exchange rate fluctuations, certain terms and Conditions apply
Includes:
--------------------------------------
The cost is all-inclusive whilst in India for selected procedure: The surgeon, specialist anesthesiologist, and private clinic/hospital stay for the required procedure with 24 hours nursing facilities, all theatre charges, medication, pre and postoperative consultations and non-refundable administration fee, for the selected procedures.
Medical evaluation, Email correspondence and Telephonic consultations.
Pre and Post operative instructions for your selected procedures.
Detailed Itinerary for pre and post operative consultations.
Excludes:
---------------------------------------
Any additional medical expenses that might have incurred for the safety of your health as a result of unforeseen complications Ð please discuss with the surgeon.
Insurance.
Additional procedures.
Payment Terms:
--------------------------------------
Non Refundable Administration Fee charged as a deposit to secure your booking.
Deposit payable to MyMediTrip via bank transfer as indicated on the invoice and will be deducted from the agreed cost estimate.
Balance of the fee payable directly to the surgeon at your pre operative consultation
Payment can be made via valid Credit Card orTravellers Cheque or Cash
I have read the terms and conditions above:
Yes
No
After sending this form we request that you also send us a close up photograph of the body area you are requesting the procedure for. This will assist further medical evaluation by the surgeon.
Please be assured that all electronic data received is treated with the strictest confidentiality.
Thank you for taking the time to complete this profile.