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Medical Profile

Date*
MM slash DD slash YYYY
Patient Profile
SURNAME*
GIVEN NAME*
ADDRESS*
Street Address
Street Address
POSTCODE*
ZIP / Postal Code
TELEPHONE(PHONE)*
(WORK)
(MOB)*
EMAIL*
OCCUPATION*
DATE OF BIRTH*
AGE*
MARITAL STATUS*
MEDICARE NUMBER*
EXPIRY DATE*
REF*
HEATH INSURANCE FUND*
MEMBERSHIP NO*
VETERANS AFFAIRS NO
PENSIONER
- Yes
- No
Contact information

NEXT OF KIN
NAME*
Middle
RELATIONSHIP*
ADDRESS
Street Address
Street Address
TELEPHONE(HOME)
(WORK/MOB)
ADDITIONAL CONTACT
NAME*
Middle
RELATIONSHIP*
ADDRESS
Street Address
Street Address
TELEPHONE(HOME)
(WORK/MOB)
GP INFORMATION
LOCAL DOCTOR
TELEPHONE
ADDRESS
Street Address
SPECIALIST PHYSICIAN/SURGEON
TELEPHONE
WEIGHT LOSS HISTORY

PLEASE DOCUMENT PREVIOUS WEIGHT LOSS ATTEMPTS (EG: Weight Watchers, Jenny Craig, Fad Diets, Hypnotherapy, Appetite Suppressants, including any Weight Loss Surgery)
1.
DURATION
KG LOST
2.
DURATION
KG LOST
3.
DURATION
KG LOST
4.
DURATION
KG LOST
5.
DURATION
KG LOST
6.
DURATION
KG LOST
LIFESTYLE INFORMATION
ALCOHOL INTAKE (Standard Drinks Per Week)
CHOICE OF ALCOHOLIC DRINK
- SMOKER
(

/DAY )
- EX-SMOKER
( HOW MANY YEARS:
STOPPED:

)
- NEVER-SMOKED
CURRENT DEDICATED EXERCISE
- 0 Days/Week
- 1-2 Days/Week
- 2-4 Days/Week
- 4-7 Days/Week
- Walking/Running
- Cycling
- Swimming
- Yoga/Pilates
- Gym/Trainer
- Other
SLEEP PATTERNS
A) I CONSIDER MY SLEEP IS:
- Good
- Fair
- Poor
B) I USUALLY SLEEP:
- 6-8 Hrs
- 4-6 Hrs
- >4 Hrs
C) I HAVE SLEEP PROBLEMS:
- Yes
- No
- Sometimes
SURGICAL HISTORY

PLEASE GIVE DETAILS OF PAST OPERATIONS:
1.
2.
3.
4.
5.
WOMEN’S HEALTH
A. DO YOU HAVE REGULAR PERIODS (26-33 DAYS)?
- Yes
- No
IF NO, PLEASE PROVIDE FURTHER DETAILS
DO YOU HAVE PROBLEMS WITH HEAVY PERIODS?
- Yes
- No
IF YES, PLEASE PROVIDE FURTHER DETAILS
C. HAVE YOU HAD DIFFICULTY CONCEIVING IN THE PAST?
- Yes
- No
D. DO YOU CURRENTLY HAVE PROBLEMS WITH INFERTILITY?
- Yes
- No
E. HAVE YOU SUFFERED FROM EXCESS BODY HAIR OR ACNE?
- Yes
- No
F. HAVE YOU BEEN DIAGNOSED WITH POLYCYSTIC OVARIES?
- Yes
- No
MEDICATIONS

Please provide details-name and length of use-of any medication you are currently on, or have previously been on, for any of the following: psychiatric disorders, migraines, weight loss, epilepsy, asthma or breathing, or hormones (e.g. Pill, HRT, Cortizone).
CURRENTLY:
PREVIOUSLY:
GASTRO-OESOPHAGEAL REFLUX/INDIGESTION
1. Do You Have A History Of Heartburn Or Indigestion?
- Yes
- No
2. How Often Do You Experience Reflux (E.G., Daily, Most Days, Occasionally)?
3. How Often Do You Experience Indigestion/Heartburn During The Night?
4. What Causes/Aggravates Your Reflux?
5. What Treatments Do You Use To Relieve Your Reflux, Heartburn, Or Indigestion?
6. Do You Have Difficulty Swallowing?
- Yes
- No
7. Does Food Ever Get Stuck When You Swallow?
- Yes
- No
8. Does Food Or Fluid Reflux Back Into Your Mouth?
- Yes
- No
9. Do You Vomit When You Experience Reflux?
- Yes
- No
10. Do You Suffer From Recurrent Sore Throats?
- Yes
- No
11. Do You Suffer From A Hoarse Voice?
- Yes
- No
12. Do You Suffer From A Regular Evening Cough?
- Yes
- No
MEDICAL ASSESSMENT
Weights:

KG
HEIGHT:

CM
BMI:
NECK:

CM
WAIST:

CM
HIP:

CM
BLOOD PRESSURE:
/

MM/HG
HIGHEST ADULT WEIGHT:

KG
LOWEST ADULT WEIGHT:

KG
IDEAL WEIGHT:

KG
MEDICAL HISTORY

Have You Suffered With Any Of The Following? (Please Tick One And Provide Relevant Details Below)
1. DIABETES *NB*
- Yes
- No
2. Diabetes Whilst Pregnant
- Yes
- No
3. Asthma
- Yes
- No
4. Respiratory/Breathing Problems
- Yes
- No
5. Arthritis Or Joint Pain
- Yes
- No
6. Back Pain
- Yes
- No
7. Kidney Or Urinary Disorder
- Yes
- No
8. Neurological Problems
- Yes
- No
9. Psychological Disorders
- Yes
- No
10. Gallstones
- Yes
- No
11. Gastric/Duodenal Ulcer
- Yes
- No
12. Hepatitis Or Liver Disease
- Yes
- No
13. High Blood Pressure
- Yes
- No
14. Heart Disease
- Yes
- No
15. High Cholesterol
- Yes
- No
16. Anaemia/Bleeding Disorder
- Yes
- No
17. Thrombosis/Clotting Disorder
- Yes
- No
18. Varicose Veins Or Leg Swelling
- Yes
- No
19. Eczema Or Skin Condition
- Yes
- No
20. Hay Fever Or Rhinitis
- Yes
- No
21. ALLERGIES *NB* (Incl. Food, Medications, Dressings)
- Yes
- No
Please List All Allergies
Please Provide Details Regarding Any Of The Above Or Any Other Illnesses Or Problems Not Listed:

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Additional Resources

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Guide To Gastric Sleeve
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Guide To Gastric Balloon

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