New Bariatric Surgery Patient Intake Questionnaire
Night Sweats Hemoptysis Hoarseness Eye Pain or Blurry Vision Swelling of Lymph Node(s) Frequent Urination, Bloody Urine or Flank Pain Swelling of Joint / Vertebra Headache, Decreased Level of Consciousness or Neck Stiffness Pain / Swelling in Other Locations SOCIAL HISTORY +/- COMMENTS Tobacco use _____ pks / day _____ years of use ................
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