| It is important to be thorough in filling the medical questionnaire, listing any medical or psychological history, medication and allergies . Please give as much information as possible. |
Full Name*
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| Age* Gender |
Male
Female |
| Date of Birth (MM/DD/YY)* |
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Telephone Number* |
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| Marital Status |
Married
Single |
Height (Cms) |
Height |
| Present Weight |
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| Since when have you been overweight? |
Since Birth
Since Age of
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| At what weight did you feel your best? |
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How much weight would you like to lose? |
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- Highest acceptable weight
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| Have you tried any dieting programme? |
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| If yes, how long have you been dieting and what has been the outcome? |
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Indicate your food prefer in order of 1 to 4 as 1- like very much to 4-Don't care |
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| How do you decide when to stop eating? |
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| Do you have any food allergies? |
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| How many meals you eat in a day? |
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| Do you eat between meals? |
Yes
No |
Do you drink for reasons other than
hunger or thirst? |
Yes
No |
| How fast do you eat? |
Slow
Medium
Fast |
Do you understand the long-term changes
in food intake that will be necessary after surgery for the rest of your life? |
Yes
No |
Have you had, or do you have, any of the following illnesses or symptoms? |
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| Any other serious illness /or hospitalization you have experienced in past |
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If you smoke currently |
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Packs/day |
- How many years have you been smoking?
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Years |
| If you smoked in the past |
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Packs/day |
- How many years did you smoke?
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Years |
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If you drink beer, Liquor or wine, how
many glasses per week and since how long |
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| If you use any recreational drugs,
which one(s) |
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| Have you ever had an addiction to drugs? |
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What exercise do you do on regular
basis and with what frequency? |
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| The highest level of course pursued ? |
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Only Female patients:- |
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- Any obstetric complications?
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- Do you have regular periods?
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| Do you have any questions or concerns? |
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| Enter Code |
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