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Dr Jose A. Castaneda

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Bariatric surgeon with 5000 procedures and 7 years experience

  • 1-877-782-2848

News

Weight Loss in Mexico

After lots of information on the risks of obesity,

May 28, 2013 read more

Diabetes Surgery in Mexico

Bariatric surgery for diabetes has been found to r

May 28, 2013 read more

Nutritional Assessment – Weight Loss Surgery

ASMBS

NUTRICIÓN EN CIRUGÍA BARIÁTRICA

PRE-SURGICAL ASSESSMENT

Name:*

Brth Date:*

Phone:*

City:*

Address:*

State:*

Email:*

Profession:*

INHERITED FAMILY HISTORY
Indicates if someone in your family (parents, grandparents, uncles, etc.) have suffered or are suffering from the following diseases
DIABETES HYPERTENSION OBESITY CANCER KIDNEY DISEASE LIVER DISEASES HEART DISEASE 
PERSONAL MEDICAL HISTORY

INDICATE IF YOU HAVE HAD OR HAVE ANY OF THESE DISEASES
DIABETES HYPERTENSION OBESITY THYROID CANCER POLYCYSTIC OVARIAN KIDNEY DISEASE LIVER DISEASES HEART DISEASE CHOLESTEROL TRIGLYCERIDE ACID URIC 
GASTROINTESTINAL DISEASES
CONSTIPATION DIARREA COLITIS GASTRITIS PEPTIC ULCER HERNIA 

Other

DATE OF BIRTH

AGE

WEIGHT

HEIGHT

(IN THE LAST THREE YEARS)

HIGHER WEIGHT

LOWER WEIGHT

SINCE HOW LONG DO YOU HAVE OVERWEIGHT OR OBESITY?
CHILDHOOD LESS THAN 5 YEARS MORE THAN 5 YEARS 
REASON (POSSIBLE)
GIVE UP SMOKING BAD FOOD INACTIVITY TAKING DRUGS MENOPAUSE 

Other

WEIGHT LOSS ATTEMPTS:

YES NO 
KIND OR TYPES OF DIETS (NAMES ex. ATKINS, SUNFIRE, LOWCARBS, HIGH PROTEIN…)

WEIGTH LOSS PILLS:

YES NO 
REMEMBER THE NAME OF THE PILLS
OTHER KIND OF WEIGHT LOSS PRODUCTS

HOURS OF SLEEP:

ANGST/ANXIETY:

SLEEPLESSNESS:

DESCRIBE AN EXAMPLE OF HOW YOUR DAILY MEALS ARE:

BREAKFAST

HOUR

WHERE?

SNACK

HOUR

WHERE?

LUNCH

HOUR

WHERE?

SNACK

HOUR

WHERE?

DINNER

HOUR

WHERE?

DO YOU HAVE STABLISHED TIME FOR YOUR FOOD?

YES NO SOMETIMES 

HOW MANY MEALS DO YOU MAKE DAILY?

MORE THAN 5 5 4 3 2 1 

DO YOU CONSUME HIGH FAT FOOD?

YES NO 

HOW MUCH WATER DO YOU DRINK DAILY?

DO YOU DRINK COFFEE OR TEA?

YES NO 

CUPS/DAY

REGULAR SUGAR OR SUGAR SUBSTITUTE:

DO YOU DRINK ALCOHOL?

YES NO 

TIMES A WEEK :

MORE THAN 5 5 4 3 2 1 

DO YOU PRACTICE ANY SPORT?

YES NO 

WHAT KIND OF SPORT?

TIMES A WEEK?

MORE THAN 5 5 4 3 2 1 

HOURS PER DAY?

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