Should i do obesity surgery ?

1. Name Surname

2.Weight" (kg)

Height (cm)

3. Gender (Consider your anatomical condition without reinforcement and hormone etc.)

Woman Man

4.Age

Telephone No.

5. Mark your existing diseases and diseases.

Diabetes Type 1

Diabetes Type 2

Insulin Resistance

Heart Diseases

Hypertension

Lumbar Hernia

Gout

6. Mark your existing diseases and diseases.

Reflux

Gastritis

Insulin Resistance

Snore

Joint Disorders

Dyslipidemia(High Cholesterol)

Irregular period

Polycystic ovary

Hypothyroid

Psychological Disorders

Sexual Problems

Asthma

7. Do you have a psychiatric diagnosed drug and alcohol addiction?

Diagnosed No

8. Do you have any psychiatricly diagnosed eating disorders?

Diagnosed No

9. Please mark the chronic diseases in your family (mother, father, sibling, etc.).

Diabetes Type-1

Diabetes Type-2

Insulin Resistance

Blood pressure

Heart Diseases

Cancer

10. If you have regular medications, please write

11. Do you smoke ? (Consider the last 3 months)

Yes 1/2 Package per day Yes one package per day Yes more than one package per day No I do not use

12. Have you ever tried to lose weight before?

Yes No

13. How was your weight during puberty (up to 19 years)?

I was overweight I was full and big but I was not overweight. I was normal weight. I was thin.

14. If you want to treat the obesity problem through surgery, how will your family and / or your immediate surroundings react to you??

They will support me. Even if they don't support, they respect my decision They do'nt support this decision