Anamnesis Form

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Name Surname

First

Last

Yerleşim

E-mail

City you live in

Size

What is your target weight?

Do you have a diagnosed Metabolic Syndrome? If yes, which Syndrome? When was the diagnosis made?

Do you have hypertension? If yes, for how many years?

Do you use antidepressants? Names, Dosages, Duration of Use:

Do you have food allergies? If yes, which food?

Have you tried dieting before? If yes, how many times?

Which? (Gastric Balloon / Gastric Botox) What is your starting weight? Duration? How much weight did you lose?

How long after did the weight gain occur again? From where?

Telephone

Kilo

What is the maximum weight you see?

Surgeries you have had? If yes, which surgery? General / Local anesthesia?

Do you have diabetes? How many years? Latest HbA1c value?

Do you use any medication regularly? Names, Dosages, Duration of Use:

Do you have any stomach complaints/disorders? If yes, can you tell me? When does it happen most?

Do you have a drug allergy? If yes, which drug?

Have you tried gastric balloon / botox before?

Have you had bariatric surgery before?

If yes, which procedure? What is your starting weight? Duration? How much weight did you lose?

AntBariatric is a general surgery clinic consisting of a general surgeon, bariatric dietitian and specialist postbariatric care nurses who specialize in bariatric surgery. AntBariatric manages all care and follow-up processes during and after bariatric surgery. AntBariatric T.R. No. 15938 issued by TÜRSAB. It has a Group A Travel Agency Operating Certificate from the Ministry of Culture and Tourism.

Yıldız Mh. Yıldız Cd. 220 Sk. No: 19 ANTALYA

+90 (242) 503 3 268

info@antbariatric.com