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INTRAGASTRIC BALLON - Special Offer for this month only....
Non - Surgery, Endoscopic Placement, Patient is released the same day....

First Name:
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Surgery:	LAP-BAND GASTRIC SLEEVE BY PASS UNDECIDED
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FAMILY OBESITY HISTORY:	FATHER MOTHER BROTHERS
PERSONAL ANTECEDENTS OF THE	PATIENT
CARDIOVASCULAR	High Blood Pressure Heart Attack Stroke Heart Failure Chest Pain When Walking Varicose Veins Phlebitis-Pulmonary Embolus
RESPIRATORY	Chronic Cough/Emphysema Asthma Sleep Apnea - Mild Sleep Apnea - Severe
GASTROINTESTINAL	Hiatus Hernia and/or Heartburn Stomach Ulcers Gallstones Chronic Constipation Blood with Bowel Movement Previous Surgery
GYNECOLOGICAL	Pregnancies Premenstrual Bleeding Menstration History - Regular Menstration History - Irregular
ENDOCRINE	Thyroid Diabetes Diabetes Therapy (diet/pills/insulin) High Cholesterol/Triglycerides
PHYSO/SOCIAL	Eating Disorders(e.g. eat too much) Consultation or Therapy
JOINT PAIN	Hips Knees Ankles Lower Back
DRUGS	Diet Pills Smoking Substance Abuse
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DIET HISTORY:
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How did you hear about us?:	INTERNET FRIENDS TV PRINT ADS OTHER
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