Bariatric Questionnaire

First Name

Last Name

Gender Male Female Other

Email

Date of Birth

City

Postal / Zip Code

Emergency Contact

First Name

Last Name

Relationship

Email

Telephone No (Home)

Telephone No (Business)

Medical

Desired Destination

Desired Medical Procedure

Desired Surgery Date

Do you have a passport?: Yes No

Social Profile

Do you have children? Yes No

Current Weight

Since when have you been overweight?

Months

Weight Watchers Yes No

Jenny Craig/Nutrisystem/Gloria Marshall etc Yes No

Appetite suppressants Yes No

Any other drug treatment Yes No

Fad diets Yes No

Were there any particular events that lead to significant weight gain: Yes No

Recreational drug use Yes No

Do you smoke? Often Sometimes Never

Any allergies Yes No

Do you drink alcohol? Often Sometimes Never

Any previous surgery Yes No

Have you had any infectious diseases before? HIV Streptococcus Influenza Flu Other

Diabetes Yes No

Diabetes while pregnant Yes No

Asthma Yes No

Respiratory/Breathing problems Yes No

Arthritis or joint pain Yes No

Kidney or urinary disorder Yes No

Neurological disorder Yes No

Psychological/nervous disorder Yes No

Gallstones Yes No

Thrombosis or clotting disorder Yes No

Gastric or duodenal ulcer Yes No

Hepatitis or liver disease Yes No

High blood pressure Yes No

Heart disease Yes No

High cholesterol Yes No

Anemia or bleeding disorder Yes No

Varicose veins or leg swelling Yes No

Eczema or skin condition Yes No

Hayfever or Rhinitis Yes No

Back pain Yes No

Any other

List all medications you currently take including dosage

Do you have sleep apnea? Yes No

Do you use CPAP machine?? Yes No

Migraine Yes No

Weight loss assistance: Yes No

Epilepsy Yes No

Asthma or breathing: Yes No

Psychiatric disorder Yes No

Hormones, e.g., the pill: Yes No

HRT Yes No

Cortisone: Yes No

Blood thinners Yes No

Does being at work ever make your chest tight or wheezy? Yes No

Have you ever had asthma? Never Currently In the past Don't know

History of heartburn, acid reflux or indigestion Yes No

Pregnancies, births, abortions (if any)

How did you hear about us?

*W = Weight	Below Average	Average Weight	Above Average	Very Heavy
Birth *W
*W at beginning of high school (10-12 yrs)
*W at end of high school (15-18 years)
*W at time of commencing work (21 years)
*W at time of marriage (if applicable)

	Parent	Sibling /Child	Other Relatives	No Family History	Don't Know
*Diabetes
*Heart Disease
*Hypertension
*Gout
*Gallstones
*Obesity
*Snoring
*Asthma
*Allergies
*Hay fever
*Dermatitis /Eczema
*High Cholesterol
*Osteoporosis
*Hip fractures