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Dr. Luis A. Betances
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Obesity
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*
Names)
Surnames)
Sex
*
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M
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Country
Mobile
*
E-mail
*
Personal information
Nationality
*
ID / Passport
*
Marital status
*
Married
Single
Widower
Free Union
Occupation
Actual Weight (pounds)
*
Height
*
BMI
*
Pathological Family History:
Please mark with an X the conditions that apply.
Obesity
Grandpa
Grandma
Dad
Mother
Uncles
Siblings
Arterial hypertension
Grandpa
Grandma
Dad
Mother
Uncles
Siblings
Diabetes
Grandpa
Grandma
Dad
Mother
Uncles
Siblings
Neoplasms
Grandpa
Grandma
Dad
Mother
Uncles
Siblings
Thromboembolism / Coagulopathies
Grandpa
Grandma
Dad
Mother
Uncles
Siblings
Endocrinological Diseases
Grandpa
Grandma
Dad
Mother
Uncles
Siblings
Genetic diseases
Grandpa
Grandma
Dad
Mother
Uncles
Siblings
Other family conditions
Personal history
Onset of Obesity:
Childhood
Adolescence
Adulthood
Related to pregnancy
Menopause
Highest Weight Ever: (pounds)
Weight (pounds)
Date
Lowest Weight Ever: (pounds)
Weight (pounds)
Date
Have you tried any of these weight loss methods?
Tablets
Medical diets
Keto diet
Pronokal
Hypnosis
Acupuncture
Surgery
Tablets
*
When did you try it?
How long did it last?
How many pounds did he lose?
How much weight did you regain and in what time?
Commentary
Medical diets
*
When did you try it?
How long did it last?
How many pounds did he lose?
How much weight did you regain and in what time?
Commentary
Keto diet
*
When did you try it?
How long did it last?
How many pounds did he lose?
How much weight did you regain and in what time?
Commentary
Pronokal
*
When did you try it?
How long did it last?
How many pounds did he lose?
How much weight did you regain and in what time?
Commentary
Hypnosis
*
When did you try it?
How long did it last?
How many pounds did he lose?
How much weight did you regain and in what time?
Commentary
Acupuncture
*
When did you try it?
How long did it last?
How many pounds did he lose?
How much weight did you regain and in what time?
Commentary
Surgery
*
When did you try it?
How long did it last?
How many pounds did he lose?
How much weight did you regain and in what time?
Commentary
How many times a day you eat?
*
2 times
3 times
5 times
More than 5 times
How big are your food portions?
Do you have difficulty feeling satisfied?
How often do you exercise?
*
Everyday
3 times per week
Once a week
Do you do any sports?
*
Yes
Do not
Eating disorders
*
Yes
Do not
Psychological Therapy:
*
Yes
Do not
Depression
*
Yes
Do not
Allergies
*
Medicines
Food
What medications are you allergic to?
*
What foods are you allergic to?
*
Toxic habits
Alcohol
Tobacco
Drugs
Weight loss medication
How often do you consume alcohol?
*
How often do you smoke tobacco?
*
What type of drug do you use and how often?
*
What medicine do you take to lose weight?
*
Medications in current use
Pathological personal history
Respiratory
Select All
COPD
Bronchial asthma
Sleep apnea
Dyspnoea
Cardiovascular
Select All
Arterial hypertension
Chest pain exertion / rest
Varicose Veins
Phlebitis
Pulmonary embolism
Gastrointestinal
Select All
Acidity
Gastroesophageal reflux
Hiatal Hernia
Gastritis
Gastric or Duodenal Ulcer
Gallstones
Chronic constipation
Hepatic steatosis
Gynecological
Select All
Pregnancies
Deliveries
Caesarean sections
Abortions
Irregular menstruation
Menopause
Amenorrhea
Breakthrough bleeding
Polycystic ovary
Endometriosis
Endocrine
Select All
Hyper / Hypothyroidism
Mellitus diabetes
Hypercholesterolemia
Hypertriglyceridemia
Musculoskeletal
Select All
Hip pain
Back pain
Knee pain
Osteoarthritis
Muscle pain
Other Pathologies
Select All
Neurological
Urological
Rheumatic
Dermatological:
Dental
Previous Surgeries
Kind
Date
Comments
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