BIMC Hospital Nusa Dua
Gastric sleeve surgery is available at BIMC Hospital Nusa Dua. Please fill out the initial patient evaluation to determine if you are a candidate for gastric sleeve surgery.
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Email *
Full Name *
Email Address *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Country *
Height *
Weight *
Surgery Procedure You Like to Have *
Required
Do You Have any health issue *
Have you had surgery before *
Do You take any medications *
Any medical conditions *
No
Yes
Diabetes or blood sugar problem
Thyroid problems
heart problems
Lung problems
Blood pressure problems
blood disorders
kidney or liver problem
Previous or current history of cancer
nervous breakdown depression issue
neurological problems
anesthesia problems
others
Stop bang test *
NO
yes
do you snore loudly
do you feel tired fatigue or sleepy during the day
Have you been told to stop breathing during your sleep
is your body mass index greater than 35
are you 50 years older
are you male with neck circumference greater than 17 inches or a female with neck circumference greater than 16 inches
Declaration *
Required
A copy of your responses will be emailed to the address you provided.
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