Please provide your contact details, then answer the questionnaire below. When you are comfortable with your answers, select [SUBMIT]. Provided you select the option, you will be emailed a copy of what you have submitted.
Patient Contact etc Details
Contact Fields marked * are mandatory.
How long have you been struggling with your weight?
Less than 5 years
5 - 10 years
10 - 15 years
Over 15 years
Were you an Obese Child?
Were you Obese as a teenager?
I was kg when I was 20 years old?
What have you tried to do about your weight?
Light and Easy
Optifast or Other Shakes
Self Managed Diet/s
Diet by Dietician or Personal Trainer/s
Medications for weight loss:-
Duramine for Xanical
Other over the counter medications
Don't want to exercise
My work is very active
No time for exercise
Family history of obesity:-
No other family members are obese
A few of my family are obese
Most of my family are obese
Members of my family have had obesity surgery
How does your weight affect you:-
Harming my health
Limits my physical activities
Can't cope with my work
Can't attend family functions
Social isolation and phobia
Can't fit in seats in Cinemas Aircraft etc
I suffer from Asthma
I suffer from Emphysemia
I suffer from Bronchiactesis
I DO smoke cigarettes a day and have done so for years.
I DID smoke but stopped years ago.
I suffer from sleep apnea. I am using CPAP.
I snore heavily.
I have had a heart attack.
I have had an angiogram.
I have had a stent inserted.
I am on blood thinning medication.
I have had open heart surgery.
I suffer from cardiomyopathy (enlarged heart).
I suffer from Hypertension.
I suffer from High Cholesterol.
I suffer from Congenital Heart Disease.
I have a Pace Maker.
I have irregular heart rythm (Arrythmia).
I have a history of family members under 40 having heart problems.
I am on the following medications related to heart disease please list
Women's HealthIf you are male please skip this section
I am past menopause.
I am pre-menopausal and get my periods every days. I bleed heavily.
I have had children and miscarriages.
I suffer from infertility and have tried IVF times.
I suffer from facial acne.
I have or have had Breast Cancer.
My family has a history of Breast Cancer.
I suffer from Pelvic Floor weakness.
I suffer from anxiety.
I have attempted self harm.
I have had suicidal thoughts.
I suffer bipolar disorder.
I suffer from schizophrenia.
I suffer from bulemia.
I am on the following medications related to my mental history please list
I have thyroid problems.
I suffer from osteoporosis.
I suffer from pitutarty tumors.
I suffer from adrenal tumors.
I am on the following medications related to my endocrinological conditions please list
How many meals do you consume daily?
Do you skip breakfast?
Do you graze between meals?
Do you eat until you fall asleep?
Do you wake up at night hungry looking for food?
Do you keep excess sweet stocks at home?
Soft drink consumption
Do you drink energy drinks V, Mother, Red Bull etc?
I drink cups of coffee a day with spoons full of sugar in each.
Do you have a sweet tooth?
Do you cook at home?
Do you think organic and non-processed food is important for health?
Do you drink liquid with your food?
What time do you go to bed?
How Many hours do you sleep daily?
Do you do shift work?
Do you work at night?
Do you use medication to fall asleep?
Do you find it difficult to wake up in the morning?
Do you suffer from any sleep disorder?
Do you have an exercise program?
Do you have a personal trainer?
I exercise hours a week.
I exercise at a Gym.
I exercise using home Gym equipment.
I exercise by walking.
My work is very physical.
I cannot exercise because:
I have severe Arthritis.
I have to use walking aids.
Because of my weight.
I do not like exercise.
How important is it for you to lose weight?
I want to reclaim my life.
I want to improve my physical ability.
I want to improve my sexual performance.
I want to get pregnant.
I want to cure my diabetes.
I want to improve my health and prevent diseases.
I want to reduce the risk of cancer.
I want to look good.
My spinal or orthopaedic surgeon wants me to lose weight.
My cardiologist wants me to lose weight.
My diabetes doctor wants me to lose weight.
I want to lose weight because:
My weight goal is kg.
How long have you been thinking about surgery?
I have had the following weitht loss surgery:
Vertical sleeve gastrectomy.
Have you met anyone who has had weight loss surgery?
I have researched surgery by:
Met a few people who have had weight loss surgery.
Searched online etc.
Attended a seminar.
What surgery would you like to have?
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successfully your survey to Sydney Metabolic Surgery
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