Personal Details

Name:    
 
Address:    
 
Home Phone:    
 
Mobile Phone:    
 
Date Of Birth:    
 
Age:    
 
Ocupation:    

Email:    

Health Ensurance Fund:    
 
Membership No.:    
 
Veterans Affair No.:    
 
Pensioner :    
 
Surgery Suggested Date (DD/MM/YY):    

Contact Persons:
This information is often vital to us if we need to contact you urgently. Occasionally people move or have new phone numbers and do not let us know.

Next of kin.

Name:    
 
Relationship:    
 
Address:    
 
Home Phone:    
 
Mobile Phone:    

Additional Contact.

Name:    
 
Relationship:    
 
Address:    
 
Home Phone:    
 
Movile Phone:    

Referral information.

 
Referring Person:    
 
Date of Referral:    
 
Phone Contact:    
 
Local Doctor:    
 
Address:    
 
Phone Contact:    
 
Specialist Physician/Surgeon:    

Social Profile.

 
Family Structure:    
 
Marital Status:    
 
Children/Ages:    
 
Support persons/friends:    
 
Do you have a pet?    
 
If so, give details:    

WEIGHT HISTORY

Please indicate your weight at the following times. Please indicate whether you consider your weight was below average (BE), average (AV), above average (AA) or very heavy (VH).

Birth Weight:    
 
Weight at starting school (5-6 years):    
 

Weight at beginning of high school (10-12 years):    

 
Weight at end of high school (15-18 years):    
 
Weight at time of commencing work (21 years):    
 
Weight at time of marriage (if applicable):    
 
Current weight:    
 
Height:    
 
BMI:    

WEIGHT LOSS HISTORY

Past attempts

Weight Watchers:    
 
Duration:    
 
Jenny Craig/Nutrisystem/Gloria Marshall etc:    
 
Duration:    
 
Hypnotherapy:    
 
Duration:    
 
Fad diets:    
 
Duration:    
 
Appetite suppressants:    
 
Duration:    
 
Any other drug treatment:    
 
Duration:    
 
Was there any particular event that lead to significant weight gain:   
 
Details of any other weight loss measures (including surgical):   
FAMILY MEDICAL HISTORY
Do you have a family history of any of the following and if so, please indicate

Diabetes, Heart Disease, Hypertension, Gout, Gallstones, Obesity, Snoring/Sleep Apnea, Asthma, Allergies, Hayfever, Dermatitis/Eczema, High Cholesterol, Osteoporosis, Hip Fractures:    

 
ALLERGIES (including foods, medications, dressings):    
 
If yes, please give details:    

ALCOHOL:

How often do you drink alcohol?:    
 

How many standard glasses do you drink per day?:    

 
How many days do you drink per week?:    
 
What do you usually drink?:    

SMOKING:

Do you smoke?: 

 

If yes, how many per day?: 

 

If so, how many per day?:  

 

For how many years?

When did you stop smoking?:    

There is increasing evidence that alcohol consumption may help some of the risk factors that lead to heart disease and stroke. Indeed it may even decrease the mortality associated with these serious conditions.

We wish to look at these risk factors in people who are obese.   To assist us we would like you to answer these few simple questions about your alcohol consumption and a few questions about any folate or multivitamins you may take.

 

Do you drink any alcohol?:        (If NO, please go to part “B”)

 

How often do you have a drink containing alcohol?:    

 

What is the main type of beverage you drink?:    

 

When do you usually drink?:    

If you indicated above that you drank every day, most days or most weeks, please tell how many standard drinks you would have in a typical week. ( 1 standard drink = 1 small glass of wine, 1 glass of full strength beer or a nip of spirits).

Part B- for non-drinkers only.

 

Is there a reason you don’t drink any alcohol?:    

Part C

Do you take multivitamin tablets or other dietary supplements?:    

 

If yes, how often do you take them?:    

 

Please name the  multivitamin or other dietary supplements you usually take.

Do you take folate tablets?:    

 

If yes, how often do you take them?:    

 

What dose do you take?:    

Ladies:

Do you have regular periods?:   

 

If not, please describe:   

 

Do you have problems with excessively heavy periods?:    

 

If Yes, please describe:    

 

Have you had difficulty in conceiving in the past?:    

 

Do you currently have problems with infertility?:    

 

Have you suffered from excess body hair or acne?:    

 

Have you ever been told by a doctor that you have polycystic ovaries?:    

 

Have you had problems with pregnancy and/or childbirth?:    

 

If so, in what way:    

 

Have you had a caesarean section?:    

 

If so, why?:    

SURGICAL HISTORY

Please give details of any past operations::    

PERSONAL MEDICAL HISTORY

 

From the list below please tell if you have suffered with any health problems:    

Diabetes, Diabetes while pregnant, asthma, respiratory/breathing problems, arthritis or joint pain, back pain,  kidney or urinary disorder, neurological, psychological/nervous disorder, gallstones, reflux or heartburn, gastric or duodenal ulcer, hepatitis or liver disease, high blood pressure, heart disease, high cholesterol, anaemia or bleeding disorder, thrombosis or clotting disorder, varicose veins or leg swelling, eczema or skin condition, hayfever or rhinitis.

Please give details of any major illnesses/problems:    

SLEEP HISTORY

 
How many hours sleep do you get a night:    
 
Is there any thing else that keeps you awake at night:    
 
Details:    
 
How do you consider the quality of your sleep:    
 
Is your sleep is a major problem to you or your partner:    
 
Would you be prepared to have a sleep study performed now and after you lose weight?:    

SYMPTOMS OF SLEEP APNEA

How often do you snore?:    
 
Do you wake during the night with a choking feeling?:    
 
How often would you sleep more than 8 hours in total in a 24 hour period?:    
 
How often do you wake up more than once during the night?:    
 
Do you have a headache when you wake up in the morning?:    
 
Have you noticed a reduction in your libido or sex drive?:    
 
Do you feel sleepy during the day?:    

Has anyone noticed that you momentarily stop breathing during your sleep?:    

 
Do you fall asleep while reading?:    
 
Do you wake up in the morning feeling confused?:    
 
How often do you have a nap during the day?:    
 
Do you feel sleepy in the evenings?:    
 
Have you or anyone else noticed a change in your personality recently?:    
 
How often do you doze off or fall asleep while driving?:    

EMPLOYMENT

Current Employment:    
 
Are you currently employed:    
 
Are you full-time, part-time or casual:    
 
If you are unemployed, what is the reason:    
 
Are you actively looking for work:    
 
Has your weight made it difficult to find employment:    
 
If employed, please state what level of activity your job involves:  

MEDICATIONS

Please indicate whether you are now or have previously taken any of the following medications
 
If yes, please state the name of the medication and how long you have been or were taking it

Medication for psychiatric disorder, Migraine medication, Medications to assist weight loss, Drugs for epilepsy, Drugs for asthma or breathing, Hormones, e.g. The Pill, HRT, Cortisone.

Please list in detail all medications that you have used in the last 12 months.  Please include any dietary supplements, cremes, eye drops, etc.:    

BREATHING HISTORY

Does being at work ever make your chest tight or wheezy:    
 
Details:    
 
Have you ever had to change your job because it affected your breathing:    
 
Details:    
 
Have you ever worked in a job, which exposed you to vapours, gas dust or fumes:    
 
Details:    

ASTHMA

Have you ever had asthma?:    
 
Have you ever had to spend a night in hospital because of asthma / breathing problems?:    
 

If yes was it in the last 12 months?:    

 
In the last 12 months, have you visited a hospital casualty department or seen a doctor urgently because you had asthma or breathing problems?:    
 
Details:    
 
In the last 12 months, have you taken a course or prednisolone because of asthma or breathing problems?:    
 
Details:    
 
In the last 12 months, have you missed work or school because of asthma or breathing problems?:    
 
COUGH AND SHORTNESS OF BREATH:    
 
Do you usually have a cough:    
 
Do you usually bring up phlegm from your chest when you cough:    
 
Do you get short of breath on exertion:    
 
Do you get short of breath walking on the flat:    
 
Do you get short of breath walking uphill or doing housework:    
 
In the last 12 months, have you had an attack of shortness of breath that came on when you were not exercising and without obvious cause:    

WHEEZE   (a whistling noise that cames from the chest and may cause breathlessness or difficulty in breathing)

In the last 12 months, have you had wheezing in your chest:    
 
In the last 12 months, have you had an attack of wheezing that came on after you stopped exercising:    
 
In the last 12 months, have you had a feeling of tightness in your chest on waking in the morning:    

ACTIVITY LEVEL

What exercise do you do on a regular basis?:    
 
How many sessions of exercise (walking, sports, etc.) do you do per week for more than 30 minutes at a time?:    
 
What sort of activities:    
 
How do you feel when exercising:    

GASTRO OESOPHAGEAL 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 aggrevates 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?:    

Do you suffer from a regular cough at night?:    

Please list any treatments you may use for reflux / heartburn or indigestion:    


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