Name *

First Name *

Date of birth *

Height

Weight

Do you smoke cigarettes or electronic cigarettes?

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Do you drink alcohol?

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Do you use drugs?

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Do you have high blood pressure? *

Do you suffer from gastric reflux? *

Do you suffer from heartburn? *

Are you taking any stomach medication *

Do you have diabetes? *

From the following health problems, select those from which you suffer or have suffered *

Among the following choices, select those that concern you *

Other people in my immediate family suffer from obesity I have had weight problems since my childhood or adolescence I have done several weight loss diets I have difficulty walking My weight is increasing every year None of these apply to my condition

Among the following procedures, check all the ones you have undergone

Cholecystectomy (stones in the gallbladder) Appendectomy Incisional hernia Hiatus hernia cure Bowel resection Hysterectomy Caesarean Tubal ligation Abdominoplasty

Have you ever had weight loss surgery? *

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Sleep apnea: select the statement that applies to your situation

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Sleep apnea: if you have never been screened, check the statements that apply to your situation

I snore loudly I am tired during the day or experience drowsiness during the day Someone has told me that I stop breathing in my sleep, or I wake up feeling like I have run out of air

What do you think your weight problems are?

Large portions Fast food Sweet foods Snacking Your emotions Physical inactivity

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