Medical History Form

The information you provide will help us plan your treatment. Please read carefully.

How to Become a Patient at Oasis of Hope

If you are ready to undergo weight loss surgery, the Oasis of Hope Bariatrics team makes the process simple. We'll guide you through your medical screening, pre-surgery tests, and pricing information. Reach out to us today to begin discussing weight loss surgery at our beautiful facility in Tijuana, Mexico.

Personal Information

Surgery of Interest

If you selected Other, please answer the following question

Have you had previous bariatric surgery?

If your answer is yes, please answer the following questions

Was your past procedure

Medical History

Tell us a bit more about your past medical history. This will help our medical staff create a better medical profile.

Are you allergic to any medication?

If your answer is yes, please answer the following questions

Are you taking blood thinners?

If your answer is yes, please answer the following question

If your answer is yes, YOU SHOULD stop taking them 15 days before the surgery to avoid any complications.

Have you been diagnosed with heart disease?

If your answer is yes, please answer the following questions

Please tell us when you where diagnosed with heart disease

If you have any study referred to your heart disease condition, please make sure to send it in advance.

Have you been diagnosed with diabetes?

If your answer is yes, please answer the following questions

Please tell us when you where diagnosed with diabetes

Please let us know what kind of treatment do you use, if you are insulin dependent, if you take pills, what kind of diabetes do you have

Have you been diagnosed with thyroid disorder?

If your answer is yes, please answer the following questions

Please tell us when you had the thyroid disorder

Please let us know what kind of treatment do you use, if you take pills, what kind of thyroid you have

Have you been dyslipidemia?

If your answer is yes, please answer the following questions

Please tell us when you had dyslipidemia

If you have any study referred to your dyslipidemia, please make sure to send it in advance.

Have you been diagnosed with heart attack?

If your answer is yes, please answer the following questions

Please tell us when you had the heart attacks

If you have any study referred to your heart disease condition, please make sure to send it in advance.

Have you been diagnosed with high blood pressure?

If your answer is yes, please answer the following questions

Please tell us when you where diagnosed with high blood pressure.

Please let us know what kind of treatment do you use, doses taken etc.

Have you been diagnosed with any lung disease? (COPD)

If your answer is yes, please answer the following questions

Please tell us when you where diagnosed with lung disease.

Please describe your condition.

Have you been diagnosed with any of the following?

Do you use CPAP machine?

Do you have sleep apnea?

Do you snore?

Gynecological History

Only for women

Create a timeline with dates about your gynecological history. Example: 2007 - Birth. 2008 Abortion. 2009 Start using birth control

Social History

Alcohol

Smoking

Drugs


Terms and Conditions

I authorize Oasis of Hope Hospital and/or his designee to request medical information, if required, from any of the physicians that have listed above, as a part of this health history questionnaire. The information that is to be requested from the physicians may include but is not limited to, history and physical exams, discharge summaries, consultation reports, laboratory and image studies.

I certify that my health history information is true and correct and that I am not intentionally falsifying my health information or misleading in any way about my current health including intentionally leaving out health information. I further understand that any false statements regarding my medical history could result in cancellation of surgery and I would be responsible for all cost incurred by.

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Oasis of Hope Bariatrics | Playas de Tijuana Office

Paseo Playas de Tijuana #19 Seccion Terrazas
Tijuana, BCN 22504

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