First Name:

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Country:

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Date of Birth:

Sex:

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Surgery:

Stature:

Weight:

Occupation:

FAMILY OBESITY HISTORY:

PERSONAL ANTECEDENTS OF THE

PATIENT

CARDIOVASCULAR

RESPIRATORY

GASTROINTESTINAL

GYNECOLOGICAL

ENDOCRINE

PHYSO/SOCIAL

JOINT PAIN

DRUGS

Other Diseases (list):

Medicines:

Allergies - Food:

Allergies - Medicine:

DIET HISTORY:

Previous Diets:

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Weight Loss:

Weight Regained:

Timeframe for Surgery:

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