Medical Questionnaire for Weight Loss Surgery

Medical Questionnaire for Weight Loss Surgery
Personal Information
First Name *
Surname *
Gender *

Male Female
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Address *
Phone number *
Email *
Email
example@example.com
Occupation
Date of birth *
Height (Metres) *
Weight (Kilograms) *
How long have you been suffering with obesity?
BMI Calculator
BMI *
https://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx
Preferred Procedure
3 Preffered Operation Dates
Emergency Contact Details
Name and Surname
Address
Telephone Number
General Practitioner
Your GPs contact details. We will only contact your GP (via phone or email) with your consent.
Name and Surname
Address
Telephone number
Medical Questions
Any family diseases (e.g. cancer, heart disease, muscle disease, blood or coagulation disorder, malign hyperthermia, systemic disease etc.)?
Regarding yourself have you suffered any major illness e.g. cancer, TB, heart problems as arhythmia, ischemic heart disease, stenocardia, pulmonary problems, coagulation problem, or systemic disease, muscle disorder, malign hyperthermia etc?
Do you suffer from / have you suffered from high blood pressure?
Do you suffer from heartburn, GERD or acid reflux?
Do you suffer from sleep apnea syndrome?
Do you have any allergies?
Have you ever suffered in the past any infectious diseases?
Are you under any instructions/prescriptions from your doctor, or are you taking any self-prescribed drugs?
Have you ever had any operations under anaesthesia, what operations and what type of anaesthesia was used? (local, regional, general)?
Have you ever had an adverse reaction or problems with local/general anaesthetic, or are you aware of any complications during or after the operations?
Have you suffered any major injuries in past (broken bones etc.)?
Have you ever suffered from problems with stomach/ duodenal/ulcer?
Have you ever suffered from any systemic disease or autoimmune conditions (e.g. HIV, M.S., Arthritis)
Do you suffer from any abnormalities of the nervous system?
Do you suffer from Diabetes ? If so, is it Type I/Type II and what was your last serum glucose level and when?
Have you ever suffered from hepatitis A, B or C or Jaundice?
Do you have problems with keloid scarring (i.e thick scar tissue)?
Do you suffer from any skin conditions? e.g. Acne/Scarring, Dermatitis, Psoriasis, Eczema, Cold Sores?
Do you smoke?
Do you drink alcohol? If so, how many units per week? (1unit = 1 small glass of wine/half pint beer?
Are you awaiting any results from investigation?
Have you suffered from bowel or urinary problems?
Have you had a treatment for renal disease (infections, nephrolithiasis)?
Do you suffer from asthma?
Have you ever had any respiratory problems?
Have you ever had a spirometry done?
Have you ever had any abdominal operation?
Have you ever had any post-operative complications?
Have you ever taken blood thinning tablets?
Are you currently taking any vitamin/mineral or herbal supplements?
Have you ever suffered from excessive bleeding?
Have you ever suffered from DVT or pulmonary embolism?
Have you ever had or received treatment for Anaemia / Thalassaemia / Sickle Cell Disease?
Have you ever had a blood transfusion?
Have you ever had a stroke, heart attack, heart arythmia or angina?
Have you had a heart murmur?
Have you ever had an ECG? If yes, when?
Have you ever been treated for psychiatric disorders or been given anti-depressants?
Have you given birth or been pregnant? If so, please state No of children & problems during Pregnancy & Childbirth. e.g. Caesarean etc.
Do you take contraceptive pill?
Are you receiving treatment for thyroid gland disorders?
Are you receiving treatment for glaucoma?
Do you have feeling of stiffness around your mouth after drinking coffee?
Do you have prostate problems?
Do you have a neurological disease (epilepsy, myasthenia, headaches, paralysis of nerves, condition after stroke, borreliosis, operation of spinal discs)?
Do you have varicose veins, phlebitis (thrombosis, ambolization)?
Have you ever used hormonal medications (Prednisone, Triamc, Cortisone)?
Did any of your blood relatives have complications during or after operation (e.g.unexplained death)?
Do you have loose teeth or removable dentures or bridges?
Do you suffer from cold sores?
Bariatric Questions and Comorbidities
Do you suffer from *

High Blood Pressure PCOS Diabetes Type 2 Osteo Arthritis Degenerative Joint Disease Urinary Stress Incontinence Reproductive/ Fertility Problems Obstructive Sleep Apnea
Do you suffer from? *

High blood pressure PCOS Diabetes Type 2 Osteo Arthritis Degenerative Joint Disease Urinary Stress Incontinence Reproductive / Fertility problems Obstructive Sleep Apnea
Highest Weight in Last 5 Years (kg):
History of Obesity in Family:
Present weight (kg):
Previous Weight loss interventions
Consultation
Weight Loss
Please provide details if you previously had WLS
Yoyo Effect
Abdominal Sonography
Other Pulmonary Problems
Do You Use
Inpatient Psychiatric History
Outpatient Psychiatric History
Previously Diagnosed With
Relapse Issues
Regular Excercise
Food Consumation

Alcohol Burgers Cake Cheese Chips Chocolate Coffee Crisps Eggs Fizzy Drinks Hot or Spicy Food Ice Cream Meat / Fish Pasta Pizza Potatoes Rice Vegetables Whole Wheat Bread
Photo

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Medical Questionnaire for Weight Loss Surgery

Personal Information

Emergency Contact Details

General Practitioner

Medical Questions

Bariatric Questions and Comorbidities