Centre for Metabolic Surgery : Enquiry

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Centre for Metabolic Surgery

Dr Ramen Goel's Bariatric Program

Enquiry

Name

:

Age

:

Gender

:

Male Female

E-mail

:

Telephone

:

City

:

Height

:

Weight at present

:

Maximum Weight

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Previous Weight Loss Attempts

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WEIGHT RELATED ILLNESS

Have you had, or do you have, any of the following illnesses or symptoms?
Heart Disease	:
High Blood Pressure	:
CABG(coronary artery bypass graft)	:
Diabetes	:
Daytime drowsiness	:
Snoring	:
Heartburn/acidity	:
Thyroid problems	:
Leakage of urine with laughing/coughing/sneezing	:

List all serious illnesses/surgeries in past	:

Do you use tobacco currently If yes, how many packs/day	:
Do you drink beer, liquor or wine	:
What exercise do you do on regular basis	:

What surgical procedure are you interested in	:
Any Specific Enquiry/Questions	:

PATIENT COMMITMENT

IF YOU ARE ACCEPTED FOR SURGERY, THE FOLLOWING ARE VERY IMPORTANT TO MAINTAIN GOOD HEALTH AND TO ACHIEVE THE DESIRED WEIGHT LOSS.
Are you willing to avoid foods and beverages containing sugar	:	Yes No
Alcohol causes gastric irritation and liver damage. After surgery, frequent alcohol consumption is unwise and can be harmful. Are you willing to stop/restrict alcohol for at least one year after surgery	:	Yes No
Are you willing to make a commitment for regular follow-up	:	Yes No

You're all set. Thanks for completing the form

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Procedures

Program

Miscellaneous

Contact Us

	Endoscopic Intragastric Balloon

	Laparoscopic Gastric Band

	Lap Gastric Bypass

	Lap Sleeve Gastrectomy

	Lap Bilio-Pancreatic Diversion

	Lap Duodenal Switch

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	Post-op Care

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	Medical Tourism

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Cell: +91 9323599309

Site: www.obesitysurgery.in

Email: info@obesitysurgery.in

Bariatric Physician & Co-ordinator

125, MRC Building, Bombay Hospital,
New Marine Lines, Mumbai-400020, INDIA

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