Food Questionnaire

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Plastic Surgery
Bariatric Surgery
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BACK TO HOME
Plastic Surgery
Bariatric Surgery
Payments
English
- Spanish

"*" indicates required fields

General Information

Name*

Last Name*

Age*

Gender*

Date of birth*

MM slash DD slash YYYY

Religion*

Education level*

Preferred Language?*

Email*

Cell Phone*

Home Phone*

Are you a post bariatric patient?*

YES

Explain*

Do you suffer heartburn / acid reflux?*

YES

Do you have any issues tolerating certain foods?*

YES

Please explain:*

What is your food intake capacity right now?*

1/3 of a Cup

1/2 Cup

1 Cup

Other (please explain)

Food intake capacity

How frequently do you currently eat?*

every 3 - 4 hours

every 6 hours

every 8 hours

other (please explain)

Meal frequency

What is your average protein intake daily?*

Do you have any food intolerances or allergies?*

Personal Preferences

Do you have any specific diet preference?*

Vegetarian

Vegan

Kosher

Other (please explain)

Diet preference

Are there any foods that you prefer not to eat?*

Fruits and Other

Vegetables

Proteins Grains

Grains and legumes (ie beans, lentils, rice, oats, etc)

Other

Do you drink coffe?*

YES

Type of Coffee*

Regular coffee

Decaffeinated coffee

Comments & Questions*

You will make a payment for $800 MXN, equivalent to $40 US dollars or $45 Canadian dollars.

I agree*

I have read and agree to terms of service and privacy policy.

Comments

This field is for validation purposes and should be left unchanged.

Política de Cancelación y Reembolso:

• Penalización del 100% del monto pagado en caso de no presentarse a su cita.
• Cancelaciones 1 a 2 días antes de su cita se penalizaran con el 50% del monto pagado, cancelaciones con 3 o mas días de anticipación son 100% reembolsables.
• Cambio de cita con 2 o mas días de anticipación no tienen ninguna penalización, cambios con 1 día de anticipación o el mismo día se penalizan con el 50% del monto pagado.

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