Forms Obesity History

Wed,22May2013

Obesity History

* indicates a required field

History of medical treatment for obesity

Gynecological History

Medical History

Please indicate if you have ever had any of the following medical problems:

History of diseases within your family

Indicate which family member is afflicted with the disease.

History of obesity within your family

(indicate which family member is or has been obese)

Your children

Hospitals

  • Genesys Regional
  • St. Joseph Mercy
  • Crittenton Hospital
  • North Oakland

Contact Information

Oakland Bariatrics
Dr. Marek Lutrzykowski, M.D.

Address: 10 W. Square Lake. Rd., Ste.200
Bloomfield Hills MI 48302
Phone: (248) 322-1543