Weight Surgery Application

APPLY MEDICAL PROCEDURE

Hospital Desired:

Medical Procedure:

First Name:

Last Name:

Address:

Zip code:

Home Phone:

Email:

Office Phone:

Mobile Phone:

Date of Birth:

Age:

Occupation:

Language:

Surgical Date:

Do you have a passport?

No Yes

CONTACT PERSONS:

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

Name:

Relationship:

Address:

Home Phone:

Office Phone:

REFERRAL INFORMATION

Referring Doctor:

Date of Referral:

Address:

Contact Phone:

Local Doctor:

Address:

Contact Phone:

SOCIAL PROFILE

FAMILY STRUCTURE

Marital Status:

No Yes

If married or previously married, what is your current status?

Divorced Partner/Relationship

Children/Ages:

WEIGHT HISTORY

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.

Birth Weight:

Below Average Average Weight Above Average Very Heavy

Weight at beginning of high school (10-12 yrs):

Below Average Average Weight Above Average Very Heavy

Weight at end of high school
(15-18 years):

Below Average Average Weight Above Average Very Heavy

Weight at time of commencing work (21 years):

Below Average Average Weight Above Average Very Heavy

Weight at time of marriage
(if applicable):

Below Average Average Weight Above Average Very Heavy

Current Weight:

Height:

BMI:

Waist Circumference:

Current Weight:

Apple shape Pear shape Other Don't Know

if other, please describe:

WEIGHT LOSS HISTORY

PAST ATTEMPTS

Weight Watchers:

No Yes

if yes, Duration?

Jenny Craig/Nutrisystem/Gloria Marshall etc:

No Yes

if yes, Duration?

Fad diets:

No Yes

if yes, Duration?

Appetite suppressants:

No Yes

if yes, Duration?

Any other drug treatment:

No Yes

if yes, Duration?

Details of any other weight loss measures (including surgical)

Were there any particular events that lead to significant weight gain:

No Yes

If yes, please explain

FAMILY MEDICAL HISTORY

Do you have a family history of any of the following and if so, please indicate:

Diabetes: