Questionnaire weight-loss surgery Step 1 of 4 - Personal Information 25% Your Name*Your Surname*E-Mail* Phone*Date of Birth*How did you hear about us?*RecommendationI am already a medicalfly patientGoogle AdsGoogleFacebookInstagramYouTubeInfluencerHeight*Weight*Gender*MaleFemaleDiverseWhen Can We Call You Back?*In which language would you like to receive advice?* German English Turkish Diabetes*YesNohigh blood pressure*YesNoHypothyroidism*YesNoHyperthyroidism*YesNoArrhythmia*YesNoAre you taking the pill or any other hormones?*YesNoPlease enter the name*Do you smoke?*YesNoHow many cigarettes do you smoke a day?* Have you had an outpatient or inpatient stay in the hospital, an operation, medical care or a pregnancy in the past 18 months?*YesNoWhat was the reason?*Please write down any other operations you have had (optional)Have you ever had an operation under general or partial anesthesia?*YesNoType of operation / date of operation* Do you use medication?*YesNoWhat medications do you use?*When would be your preferred date for the operation?* Date Format: DD slash MM slash YYYY
