Jump6 was the first clinic in Canada to offer the intragastric balloon for weight loss and still continues to assist thousands of men and women in achieving their weight loss goals.
Do you allow us to communicate with your family Physician ?
Is this visit regarding a Worker’s Compensation claim?
How did you hear about Jump6?
01. Are you taking any medicine or pills for your heart?
02. Are you taking any medicine or pills for your blood pressure?
03. Are you taking any medicine or pills (including inhalers) for your breathing?
04. I have the following
Shortness of breathIrregular heartbeatPalpitationsHeart murmurAngina
05. Do you smoke
A daily coughAsthmaBronchitisLung disease
If yes, how many cigarettes, pipes, cigars, etc. packs per day?
06. Do you consume alcohol?
If yes, how much?
07. Have you had any recent change in weight?
If yes, how much?
08. To the best of your knowledge, are you ALLERGIC to anything?
If yes, please list food, latex, and drug allergies
09. Within the last year have you taken any medicine or pills for rheumatism, arthritis or allergies?
10. Are you taking a drug called CORTISONE, PREDNISONE OR ACTH, or have you taken it within the last two (2) years?
11. Have you taken any tranquilizers or NERVE PILLS in the last three (3) weeks?
12. Have you ever been under the care of a psychiatrist?
13. Do you take any MEDICINE, PILLS, EYE DROPS, INJECTIONS (also include any non-prescription drugs, inhalers or herbal preparations)?
If yes, please list drugs, including dosage and how many times per day you take them
14. Do you have diabetes?
If yes, how long have you been a diabetic?
15. Do you have epilepsy?
If yes, when was your last seizure?
16. When was your last General Anaesthetic?
Procedure? And in what hospital?
17. Have you ever had a REACTION or COMPLICATION to a LOCAL or GENERAL anaesthetic?
If yes, in what hospital?What type of reaction occurred?
What type of reaction occurred?
18. Has anyone in your family ever had a reaction to anaesthetic?
If yes, what type of reaction?
19. Have you or anyone in your family ever been tested for MALIGNANT HYPERTHEMIA or had a malignant hyperthermia reaction (high body temperature as a reaction to drugs used during surgery)?
If yes, name the family member/phone number
20. Do you suffer from sleep apnea?
21. Have you ever been tested for H.I.V. antibodies (A.I.D.S.)?
If yes, when?
22. Do you or anyone in your family bleed excessively?
If yes, explain
23. If you have ever had any of the following, if yes, please select them and explain
HepatitisKidney diseaseRheumatoid arthritisPhlebitisHeart diseaseLiver disease or jaundiceAnemiaCancerEnlarged lymph glandsStrokeBlackoutsHiatus herniaUlcerTransient ischemic attacks (TIA's)
24. List any OPERATIONS you have had in your life
25. List below the illnesses you have had during your life not already noted on this form
26. If female, are you pregnant?
27. Tested positive for
28. I have
29. Who is driving or accompanying you home?
30. Have you signed the Consent for Operation?
31. When did you last have something to eat or drink?
32. Contact in Emergency
There is life and beauty after pregnancy with a mommy makeover. At Jump6 of Toronto, a mommy makeover is the combination and procedures.
Cosmetic surgery procedures for men can give men a thinner waist, fewer wrinkles and increased overall body confidence.