Patient Health Survey
Please fill out all 5 pages of this form in as much detail as possible.
Patient Name:
*
Title
First Name
Last Name
Date of Birth:
*
-
Day
-
Month
Year
Calculate your Body Mass Index (BMI) below by entering your weight (kgs) & height (cm) below:
*
What is your occupation?
Full time
Part time
Casual
Unemployed
Main diagnosis/symptoms (brief):
*
What has been the duration of this condition/symptoms?
*
Have you had any previous surgeries/operations?
*
Yes
No
Details of Surgery Type 1:
Date of Surgery:
Details of Surgery Type 2:
Date of Surgery:
Details of Surgery Type 3:
Date of Surgery:
Has your GP ordered any blood tests or X-rays recently?
*
Yes
No
If so, which Pathology company?
Date of Pathology
If so, which X-ray company?
Date of X-ray
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Weight Loss Surgery
Depending on your answer to the below question, we may ask more detailed questions relating to your lifestyle and other weight loss surgery specific questions.
Are you interested in or wanting to have weight loss surgery (Bariatric Surgery)?
*
Yes
No
Maybe / Unsure
What is the heaviest weight you have been (kgs)?
When were you at your heaviest weight?
How does your family feel about your decision to have bariatric surgery?
Who is your key support person?
Who does the cooking at home?
What types of weight reduction diets have you tried in the past? Please list each one:
Exercise: What forms of exercise do you do?
How often do you exercise?
How many steps can you climb without getting puffed?
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Medications
Please list your prescribed and non-prescribed medications along with the dose you take. Alternately upload a list of your medications using the file upload button below.
Medication 1:
Dose:
Medication 2:
Dose:
Medication 3:
Dose:
Medication 4:
Dose:
Medication 5:
Dose:
Upload list of medications:
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Please upload a list of your current medications & dosage.
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Are you regularly taking any of the following medications?
Aspirin
Iscover
Plavix
Warfarin
Xarelto
Pradaxa
Fish Oil
Other
Do you take any dietary supplements or oils including:
Ginger
Ginseng
Garlic
Fish Oil
Other
Are you allergic to any of the following?
Medications
Tapes (steri-strips etc)
Antiseptics
Contrast Agent (X-ray)
Bandaids
Latex
Foods
Other
If you ticked 'Yes' to having allergies above, please give list the names you remember of the things you are allergic too:
Have you ever experienced any problems with Anaesthetics in the past?
Yes
No
If 'Yes', please describe below:
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Lifestyle & General Health
Your Family History
Rows
Current Age
Medial History
Are they Overweight?
Father
Yes
No
Mother
Yes
No
Sibling 1
Yes
No
Sibling 2
Yes
No
Sibling 3
Yes
No
Son
Yes
No
Daughter
Yes
No
Smoking History:
*
Smoker
Non-Smoker
Ex-Smoker
Duration of your smoking (years):
How many years have you been/were you a smoker?
Cigarettes/day:
Alcohol intake:
*
Number of standard drinks/week
Recreational Drugs:
*
Yes
No
Details:
Hearing Impairment:
*
Yes
No
Details:
Visual Impairment:
*
Yes
No
Details:
Mobility Impairment:
*
Yes
No
Stick
Frame
Crutches
Other
Do you have any chewing problems?
Dentures
Crowns/caps on teeth
Loose / missing teeth
Other
Your sleep patterns - Do you suffer from the following sleep conditions?
*
Sleep apnoea / Snoring
Day time tiredness or sleepiness
Sleep Disorder
No sleep problems
Other
Is there a moderate chance of dozing when doing the following:
Watching TV
Sitting reading
Being in the car for an hour as passenger
Sitting quietly after a meal
Being in a car when stopped at traffic lights
Have you had any mental health problems? Please provide detail below:
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Women's Health
The questions below need only be filled out by patients who identify as female.
Are you on the oral contraceptive pill?
Yes
No
If yes, how long have you been on the Pill?
Are you pregnant?
Yes
No
Are you breast feeding?
Yes
No
Are you wishing to become pregnant soon?
Yes
No
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Medical Conditions (current & previous)
Please tick any conditions/symptoms you have and provide details below:
Have you been hospitalised/had medical care for an extensive period of time? Please provide details below:
Have you ever had any of the following? Please indicate:
Diabetes
Asthma
Kidney Disease
Reflux
AIDS/HIV
Heart Disease
Gall stones
Hepatitis
Epilepsy
Blood Clots in your lungs
Any bleeding problems?
High Blood Pressure:
*
Yes
No
Details:
High Cholesterol:
*
Yes
No
Details:
Heart Conditions:
Heart attack
Angina
Heart Surgery/Coronary Stent
Palpitations
Pacemaker
Other
Details of heart condition:
Lungs/Breathing Conditions:
Asthma
Tuberculosis
Bronchitis
Sleep problems/apnoea
Emphysema
Walking up one flight of stairs causes breathing difficulties.
Other
Details of lung/breathing condition:
Gastrointestinal Conditions:
Crohn's
Peptic ulcers
Ulcerative colitis
Gallstones
Coeliac's disease
Hepatitis
Diarrhoea
Constipation
Recent change of bowel habit
Rectal bleeding
Nausea
Vomiting
Vomiting Blood
Weight loss
Loss of appetite
Other
Details of gastrointestinal condition:
Endocrine Conditions
Diabetes Type 1
Diabetes Type 2
Thyroid problems
Other
Details of endocrine condition:
If you have Diabetes, is it controlled by:
Diet
Tablets
Insulin
Other
Are you currently taking the following for your Diabetes:
Metformin
Jardiance
Jardiamet
Forxiga
Other
Neurological Conditions:
Strokes/Mini-strokes
Epilepsy/Fits
Multiple Sclerosis
Other
Details of neurological condition:
Kidney/Prostate Conditions:
Kidney Stones
Dialysis
Prostate problems
Other
Details of kidney/prostate condition:
Blood disorder:
Anaemia
Bleeding disorders
Clots in the legs or lungs
Blood transfusions
Other
Details of blood disorder:
Cancer:
*
Yes
No
If yes; where?
Date of diagnosis:
Cancer Treatment:
Surgery
Chemotherapy
Radiotherapy
Details of cancer diagnosis:
List any other medical conditions or symptoms you have (or attached a separate page if necessary using the Upload File button below):
Attach further information/diagnostics here:
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Select a file from your computer to attached and submit with your online form.
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Privacy & Consent
By ticking this box, I give my consent for Dr Jane Ghadiri to use my information to communicate with other health professionals. I also give consent to Dr Jane Ghadiri obtaining relevant information about myself from other health professionals.
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