Weight Surgery Application
APPLY MEDICAL PROCEDURE
Date of Birth:
Do you have a passport?
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
Date of Referral:
If married or previously married, what is your current status?
Please indicate your weight at the following times. Please indicate whether you consider your weight was below average, average, above average or very heavy in the relevant boxes.
Weight at beginning of high school (10-12 yrs):
Weight at end of high school (15-18 years):
Weight at time of commencing work (21 years):
Weight at time of marriage (if applicable):
if other, please describe:
WEIGHT LOSS HISTORY
if yes, Duration?
Jenny Craig/Nutrisystem/Gloria Marshall etc:
Any other drug treatment:
Details of any other weight loss measures (including surgical)
Were there any particular events that lead to significant weight gain:
If yes, please explain
FAMILY MEDICAL HISTORY
Do you have a family history of any of the following and if so, please indicate:
Snoring / sleep apnea:
Dermatitis / Eczema:
ALLERGIES? (including foods, medications, dressings)
If yes, please give details
Do you drink alcohol?
How many standard glasses do you drink per day?
How many days do you drink per week?
What do you drink?
Do you smoke?
If yes, how many per day?
Have you smoked in the past?
If so, how many per day?
If so, for how many years?
If so, when did you stop smoking?
SURGICAL HISTORY – Please give details of any past operations:
PERSONAL MEDICAL HISTORY
Have you ever suffered with any of the following health problems?
if yes, Details?
Diabetes while pregnant:
Arthritis or joint pain:
Kidney or urinary disorder:
Reflux or heartburn:
Gastric or duodenal ulcer:
Hepatitis or liver disease:
High blood pressure:
Anemia 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
How many hours sleep do you get a night?
Is there any thing else that keeps you awake at night?
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?
Do you feel sleepy during the day?
Has anyone noticed that you momentarily stop breathing during your sleep?
How often do you doze off or fall asleep while driving?
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
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:
Medications to assist weight loss:
Drugs for epilepsy:
Drugs for asthma or breathing:
Hormones, e.g.The Pill:
Please list in detail all medications that you have used in the last 12 months. Please include any dietary supplements, cremes, eye drops, etc.
Does being at work ever make your chest tight or wheezy?:
Have you ever had asthma? (tick one of the following):
GASTRO ESOPHAGEAL 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 aggravates 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
Please, specify pregnancies, births, abortions
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