Patient Questionnaire

Patient Contact Details


MaleFemale

Weight History


Less than 5 years5 - 10 years10 - 15 yearsOver 15 years


YesNo


YesNo

What have you tried to do about your weight?


Weight WatchersJenny CraigTony FergusonLight and EasyAtkins DietSure SlimOptifast or Other ShakesSelf Managed Diet/sDiet by Dietician or Personal Trainer/sOther Diet/s

DuramineXanicalReductileOther over the counter medications

GymRegular walkingPersonal TrainerCan't exerciseDon't want to exerciseMy work is very activeNo time for exercise

No other family members are obeseA few of my family are obeseMost of my family are obese

Not muchHarming my healthPsychological stressLimits my physical activitiesCan't cope with my workCan't attend family functionsBack PainSexual difficultiesSocial isolation and phobiaCan't fit in seats in Cinemas Aircraft etc

Systematic Review


I suffer from AsthmaI suffer from EmphysemiaI suffer from BronchiactesisI DO smokeI DID smoke but stoppedI suffer from sleep apnea.I am using CPAP.I snore heavily.

Others:

Cigarretes a day

Years have done smoking?

Stop smoking years ago:


I have had a heart attack.I have had an angiogram.I have had a stent inserted.I am on blood thinning medication.I have had open heart surgery.I suffer from cardiomyopathy (enlarged heart).I suffer from Hypertension.I suffer from High Cholesterol.I suffer from Congenital Heart Disease.I have a Pace Maker.I have irregular heart rythm (Arrythmia).I have a history of family members under 40 having heart problems.

Women's Section

Health

I am past menopause.I am pre-menopausalI bleed heavily.I suffer from infertility and have tried IVFI suffer from facial acne.I have or have had Breast Cancer.My family has a history of Breast Cancer.I suffer from Pelvic Floor weakness.




Mental History

I suffer from anxiety.I have attempted self harm.I have had suicidal thoughts.I suffer bipolar disorder.I suffer from schizophrenia.I suffer from bulemia.

Endocrinology

I have thyroid problems.I suffer from osteoporosis.I suffer from pitutarty tumors.I suffer from adrenal tumors.

Eating Habits









Coffee:












Sleep Habits








Exercice





I exercise at a Gym.I exercise using home Gym equipment.I exercise by walking.My work is very physical.

I have severe Arthritis.I have to use walking aids.Because of my weight.I do not like exercise.

Weight Loss

I want to reclaim my life.I want to improve my physical ability.I want to improve my sexual performance.I want to get pregnant.I want to cure my diabetesI want to improve my health and prevent diseases.I want to reduce the risk of cancer.I want to look good.My spinal or orthopaedic surgeon wants me to lose weight.My cardiologist wants me to lose weight.My diabetes doctor wants me to lose weight.




Lap band.Sleeve.Bypass.Vertical sleeve gastrectomy.Gastric Balloon.



Met a few people who have had weight loss surgery.Searched online etc.Attended a seminar.


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