Health History Questionnaire

Dr. Jalil Illan Fraijo /For Patients

For Dr. Illan to determine whether you qualify for a bariatric weight loss surgery, we need you to fill out a Health History Questionnaire.

Please note that for your convenience, we recommend installing Adobe Reader on your device to be able to easily work with the form.

Once you have completed the Health History Form, please take a moment to look over it one last time, to make sure that all questions have been answered accurately. It is very important for us to have a complete understanding of your health status as we help you to prepare for the surgery.

We hope to see you among our happy patients!