Questionnaire

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PERSONAL DETAILS

Name

Last Name

E-mail

Telephone No: (Home)

(Business)

(Mobile)

Address

City

State

ZC

Date Of Birth

Age

Ocupation

Prospective Surgery Date

Patient Coordinator

CONTACT PERSONS

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.

Name

Relationship

Address

Telephone Home

Telephone Bus

FAMILY STRUCTURE

Marriage status

Name of Partner Spouse

Childern/Ages

WEIGHT HISTORY

Minimum Weight in Adulthood

Max Weight in Adulthood

Current Weight

Height

BMI

WEIGHT LOSS HISTORY

Appetite suppressants

Duration

Any other drug treatment

Duration

Details of any other weight loss measures (including surgical)

Was there any particular event that lead to significant weight gain

FAMILY MEDICAL HISTORY

Do you have a family history of any of the following and if so, please indicate:

ALLERGIES

If yes, please give details

ALCOHOL

Do you drink alcohol

How many days do you drink per week

SMOKING

Do you smoke?

How many per day?

Have you smoked in the past?

How many per day?

For how many years

When did you stop smoking?

Do you take multivitamin tablets or other dietary supplements?

Please name the multivitamin or other dietary supplements you usually take

LADIES

Do you have regular periods (26 - 33 days)

If not, please describe

Do have problems with excessively heavy periods

If not, please describe

SURGICAL HISTORY

Please give details of any past operations:

PERSONAL MEDICAL HISTORY

Have you ever suffered with any of the following health problems:

Diabetes

Details:

Asthma

Details:

Respiratory

Details:

Arthritis or joint pain

Details:

Back pain

Details:

Kidney or urinary disorder

Details:

Neurological

Details:

Psychological/nervous disorder

Details:

Gallstones

Details:

Reflux or heartburn

Details:

Gastric or duodenal ulcer

Details:

Hepatitis or liver disease

Details:

High blood pressure

Details:

Heart disease

Details:

High cholesterol

Details:

Anaemia or bleeding disorder

Details:

Thrombosis or clotting disorder

Details:

Varicose veins or leg swelling

Details:

Eczema or skin condition

Details:

Hayfever or Rhinitis

Details:

Please give details of any major illnesses/problems:

MEDICATIONS

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

Details:

Migraine medication

Details:

Medications to assist weight loss

Details:

Drugs for epilepsy

Details:

Drugs for asthma or breathing

Details:

Hormones

Details:

Cortisone

Details:

GASTRO ESOPHAGEAL REFLUX / INDIGESTION

Do you have a history of heartburn or indigestion

If yes, how often do you have reflux during the day?

Do you suffer heart burn / indigestion during the night? If so how often

What aggravates or causes your reflux?

Do you have difficulty swallowing

Does food ever get stuck

Does food or fluid reflux into the mouth

Do you vomit with reflux

Do you suffer from recurrent sore throats

Do you suffer from a hoarse voice