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ELIGIBILITY

The information submitted by you is privileged and confidential,
Obesity Goodbye does not distribute or sell this information to 3rd parties, as it is used strictly for internal purposes.

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email:*
confirm email:*
 
  State:
State for non US residents:
 
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  Phone Number:*
Date of birth :
   
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Body Mass Index Calculator
Weight: 
Height:  o
Age:  years or: 
Gender:
kg / m2
 
Medical History:
  (ej. Allergies, Hospitalizations, Previous surgeries)
Obesity related problems:
  yes no
Diabetes
Hypertension:
Bone problems:
Depression:
Sleep disorders
Physical condition
Digestive System
Heart & circulatory system
Respiratory problems
Compulsive eating
Low expectations
Isolation
Gastro Esophageal Reflux
 
  Do you have Hiatal Hernia :
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  If you answered yes, are you in treatment, what is your treament?
 
 
  Other:
  What kind of diets have you carried out? (how long?):
  Wish date for surgery:
   
  Month   Day   Year
  Who is your patient coordinator?:
  How did you find about us?:
Please, provide us with this information so we can enhance our services.
 

 


Mary

Before & After

Otra

Before & After

"Get a new life style"

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