Email: [email protected]
Name
Last Name
E-mail
Telephone No: (Home)
(Business)
(Mobile)
Address
City
State
ZC
Date Of Birth
Age
Ocupation
Prospective Surgery Date
Patient Coordinator
This information is often vital to us if we need to contact you urgently. Occasionally people move or have new phone number and do not let us know.
Relationship
Telephone Home
Telephone Bus
Marriage status SingleMarriedDivorced
Name of Partner Spouse
Childern/Ages
Minimum Weight in Adulthood
Max Weight in Adulthood
Current Weight
Height
BMI
Appetite suppressants
Duration
Any other drug treatment
Details of any other weight loss measures (including surgical)
Was there any particular event that lead to significant weight gain
Do you have a family history of any of the following and if so, please indicate:
If yes, please give details
Do you drink alcohol NeverRarelyRegulary
How many days do you drink per week
Do you smoke? YesNo
How many per day?
Have you smoked in the past? YesNo
For how many years
When did you stop smoking?
Do you take multivitamin tablets or other dietary supplements? YesNo
Please name the multivitamin or other dietary supplements you usually take
Do you have regular periods (26 - 33 days) YesNo
If not, please describe
Do have problems with excessively heavy periods YesNo
Please give details of any past operations:
Have you ever suffered with any of the following health problems:
Diabetes YesNo
Details:
Asthma YesNo
Respiratory YesNo
Arthritis or joint pain YesNo
Back pain YesNo
Kidney or urinary disorder YesNo
Neurological YesNo
Psychological/nervous disorder YesNo
Gallstones YesNo
Reflux or heartburn YesNo
Gastric or duodenal ulcer YesNo
Hepatitis or liver disease YesNo
High blood pressure YesNo
Heart disease YesNo
High cholesterol YesNo
Anaemia or bleeding disorder YesNo
Thrombosis or clotting disorder YesNo
Varicose veins or leg swelling YesNo
Eczema or skin condition YesNo
Hayfever or Rhinitis YesNo
Please give details of any major illnesses/problems:
Please indicate whether you are now or have previously taken any of the following medica-tions. If yes, please state the name of the medication and how long you have been or were taking it.
Medication for psychiatric disorder YesNo
Migraine medication YesNo
Medications to assist weight loss YesNo
Drugs for epilepsy YesNo
Drugs for asthma or breathing YesNo
Hormones YesNo
Cortisone YesNo
Do you have a history of heartburn or indigestion YesNo
If yes, how often do you have reflux during the day? Many times a dayeverydaymost daysmost weeksoccasionally
Do you suffer heart burn / indigestion during the night? If so how often Many times a dayeverydaymost daysmost weeksoccasionally
What aggravates or causes your reflux?
Do you have difficulty swallowing YesNo
Does food ever get stuck YesNo
Does food or fluid reflux into the mouth YesNo
Do you vomit with reflux YesNo
Do you suffer from recurrent sore throats YesNo
Do you suffer from a hoarse voice YesNo
