Health Questionnaire

* The information you provide will help us to propose the best treatment for you, for which we ask you to respond with care and sincerity.

Identification File

Personal History

Have you been diagnosed with hepatitis?

Are you allergic to latex?

Allergic to any medicine or food?

Indicate the medications you currently use, the frequency with which you use it, the amount and the date you started using it

Indicate the illness you suffer from, since when you have it and what treatment you are taking

Indicate if any surgery has been done, the date and reason

Have you had any surgery for weight control?

Have you suffered a heart attack?

Digestive

Have you been diagnosed with diverticulitis?

Do you have a history of ulcers?

Have you been diagnosed with ulcerative colitis?

Do you suffer from indigestion or reflux?

Have you had any Anti-Reflux surgery?

Diabetic History

Additional Information

Indicate any additional information that you think is important in the evaluation of your health status