Bariatric Virtual Consultation - VIDA Wellness and Beauty

Get in touch

Please fill out the form below to get started!

Personal Information
Name
First
Last Name
First
Gender:
- Female
- Male
Age:
Height:*
Weight:*
Pregnancies, if yes, how many?
Birthday:
Email:
Phone:
Occupation:
Personal Health History
DIABETES:
- Yes
- No
Type:
Medication:
CANCER:
- Yes
- No
Type:
HEART DISEASE:
- Yes
- No
OVERWEIGHT:
- Yes
- No
OBESITY:
- Yes
- No
HIGH BLOOD PRESSURE:
- Yes
- No
GASTRIC SYMPTOMS:
If yes, List:
Do you experience shortness of breath with physical activity?
- Yes
- No
Do you exercise regularly?
- Yes
- No
Do you have or had asthma?
- Yes
- No
Do you have tyroid problems?
- Yes
- No
Allergies:
- Yes
- No
If yes, List:
Have you been diagnosed with FATTY LIVER, CIRRHOSIS, HEPATITIS or any LIVER DISEASE?
- Yes
- No
If yes, explain:
Do you have indigestion or heart burn?
- Yes
- No
Have you been diagnosed for Lupus?
- Yes
- No
Have you been diagnosed HIV Positive?
- Yes
- No
Have you had any gastro-instenstal surgery?
- Yes
- No
Please list and current medication, supplements, or other substances*

List Any Major Illnesses

Illness:	Date:	Treatment	Outcome:

Diet History
What have you done to try to lose weight?
Are you a snacker?
- Yes
- No
Are you a volume eater?
- Yes
- No
Do you eat a lot of sweets?
- Yes
- No
Do you drink alcohol?
- Yes
- No
Frequency and amount:
Do you smoke?
- Yes
- No
Frequency and amount:
Other addictions
- Yes
- No
which ones?
Frequency and amount:
Please list any additional information you believe would assist in your health planning:
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Get A Free Virtual Consultation

Did you know you can meet with one of VIDA’s Board Certified Plastic Surgeons from the comfort of your own home? It’s easy, free, discreet, and you will receive a personalized quote made just for you.

Free virtual consultation

VIDA Wellness and Beauty

Get A Free Virtual Consultation

Contact Us

Find Us

Hours of operation

Email Us

Email Us

How can we help you?

VIDA - General Inquiries

Get A Free Virtual Consultation

Email Us