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 statusSingleMarriedDivorced
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:
ALLERGIESYesNo
If yes, please give details
Do you drink alcoholNeverRarelyRegulary
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:
DiabetesYesNo
Details:
AsthmaYesNo
RespiratoryYesNo
Arthritis or joint painYesNo
Back painYesNo
Kidney or urinary disorderYesNo
NeurologicalYesNo
Psychological/nervous disorderYesNo
GallstonesYesNo
Reflux or heartburnYesNo
Gastric or duodenal ulcerYesNo
Hepatitis or liver diseaseYesNo
High blood pressureYesNo
Heart diseaseYesNo
High cholesterolYesNo
Anaemia or bleeding disorderYesNo
Thrombosis or clotting disorderYesNo
Varicose veins or leg swellingYesNo
Eczema or skin conditionYesNo
Hayfever or RhinitisYesNo
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 disorderYesNo
Migraine medicationYesNo
Medications to assist weight lossYesNo
Drugs for epilepsyYesNo
Drugs for asthma or breathingYesNo
HormonesYesNo
CortisoneYesNo
Do you have a history of heartburn or indigestionYesNo
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 oftenMany times a dayeverydaymost daysmost weeksoccasionally
What aggravates or causes your reflux?
Do you have difficulty swallowingYesNo
Does food ever get stuckYesNo
Does food or fluid reflux into the mouthYesNo
Do you vomit with refluxYesNo
Do you suffer from recurrent sore throatsYesNo
Do you suffer from a hoarse voiceYesNo
