Patient Questionnaire Patient Contact Details Gender: MaleFemale Weight History How long have you been struggling with your weight? Less than 5 years5 - 10 years10 - 15 yearsOver 15 years Were you an Obese Child? YesNo Were you Obese as a teenager? YesNo My weight(kg) when I was 20 years old?What have you tried to do about your weight? Diet Programs: Weight WatchersJenny CraigTony FergusonLight and EasyAtkins DietSure SlimOptifast or Other ShakesSelf Managed Diet/sDiet by Dietician or Personal Trainer/sOther Diet/s Medications for weight loss: DuramineXanicalReductileOther over the counter medications Physical Activities: GymRegular walkingPersonal TrainerCan't exerciseDon't want to exerciseMy work is very activeNo time for exercise Family history of obesity: No other family members are obeseA few of my family are obeseMost of my family are obese How does your weight affect you: 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 etcSystematic Review Respiratory: 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: Cardiovascular: 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. I am on the following medications related to heart disease please list: Women's SectionHealth 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. Gets my period every Number of Children Number of Miscarriages 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. I am on the following medications related to my mental history please list: Endocrinology Diabetes: I do not suffer from diabetes.I suffer from Type 1 diabetes.I suffer from Type 2 diabetes. I have thyroid problems.I suffer from osteoporosis.I suffer from pitutarty tumors.I suffer from adrenal tumors. I am on the following medications related to my mental history please list: Eating Habits How many meals do you consume daily? A single large meal a dayThree meals a dayNot regular - depends on other factors Do you skip breakfast? NoYes Do you graze between meals? NoYes Do you eat until you fall asleep? NoYes Do you wake up at night hungry looking for food? NoYes Do you keep excess sweet stocks at home? NoYes Soft drink consumption I do not drink soft drinkI have a soft drink every now and thenI have a soft drink once a dayI have 2-3 soft drinks a dayI have more than 3 soft drinks a day Do you drink energy drinks NoYesCoffee: Cups of Coffee a day: Spoon of sugar in each: Do you have a sweet tooth? NoYes Do you cook at home? NoYes Do you take a food away? I do not eat take away foodI have take away food once a monthI have take away food 2-3 times a monthI have take away food once a weekI have take away food 2-3 times a weekI have take away food daily Do you eat in Fast Food Restaurants? I do not eat in Fast Food RestaurantsI eat in a Fast Food Restaurant once a monthI eat in a Fast Food Restaurant 2-3 times a monthI eat in a Fast Food Restaurant once a weekI eat in a Fast Food Restaurant 2-3 times a weekI eat in a Fast Food Restaurant daily Do you eat Fruit? I do not eat FruitI eat one serve/piece of fruit a dayI eat two serves/pieces of fruit a dayI eat more than two serves/pieces of fruit a day Do you eat Vegetables? I do not eat VegetablesI eat one serve of vegetables a dayI eat two to four serves of vegetables a dayI eat five or more serves of vegetables a day Do you think organic and non-processed food is important for health? NoYes Do you drink liquid with your food? NoYes Do you drink alcohol? I do not drink alcoholI have a few drinks dailyI have a few drinks weeklyI am a social drinkerI am an AlcoholicSleep Habits What time do you go to bed? 1300 (1 pm)1400 (2 pm)1500 (3 pm)1600 (4 pm)1700 (5 pm)1800 (6 pm)1900 (7 pm)2000 (8 pm)2100 (9 pm)2200 (10 pm)2300 (11 pm)2400 (Midnight)0100 (1 am)0200 (2 am)0300 (3 am)0400 (4 am)0500 (5 am)0600 (6 am)0700 (7 am)0800 (8 am)0900 (9 am)1000 (10 am)1100 (11 am)1200 (Noon) How Many hours do you sleep daily? Do you do shift work? NoYes Do you work at night? NoYes Do you use medication to fall asleep? NoYes Do you find it difficult to wake up in the morning? NoYes Do you suffer from any sleep disorder? NoYesExercice Do you have an exercise program? NoYes Do you have a personal trainer? NoYes How many hours a week? I exercise: I exercise at a Gym.I exercise using home Gym equipment.I exercise by walking.My work is very physical. I cannot exercise because: I have severe Arthritis.I have to use walking aids.Because of my weight.I do not like exercise.Weight Loss How important is it for you to lose weight? 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. I want to lose weight because: Weight Goal(kg): How long have you been thinking about surgery? Just recentlyFor over a yearFor a few years I have had the following weitht loss surgery: Lap band.Sleeve.Bypass.Vertical sleeve gastrectomy.Gastric Balloon. Other: Have you met anyone who has had weight loss surgery? NoNo but I would like toYes I have researched surgery by: Met a few people who have had weight loss surgery.Searched online etc.Attended a seminar. Other: What surgery would you like to have? Don't KnowLap BandSleeveBy PassPlease take the time to scroll through the answers you have given before submitting your patient questionnaire form.When you activate the "Submit" button below, you will successfully your survey to Sydney Metabolic Surgery Please send me an email copy of my patient questionnaire response.