Sydney Metabolic Surgery  Sydney Metabolic Surgery

 
 

   Patient Questionnaire

Globalsign Logo

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.
Name*
Email*
Phone
Age
Occupation

Weight History

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?
    Yes
    No

Were you Obese as a teenager?
    Yes
    No

I was kg when I was 20 years old?


What have you tried to do about your weight?

Diet Programs:-
    Weight Watchers
    Jenny Craig
    Tony Ferguson
    Light and Easy
    Atkins Diet
    Sure Slim
    Optifast or Other Shakes
    Self Managed Diet/s
    Diet by Dietician or Personal Trainer/s
    Other Diet/s

Medications for weight loss:-
    Duramine for
    Xanical
    Reductile
    Other over the counter medications

Physical Activities:-
    Gym
    Regular walking
    Personal Trainer
    Can't exercise
    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:-
    Not much
    Harming my health
    Psychological stress
    Limits my physical activities
    Can't cope with my work
    Can't attend family functions
    Back Pain
    Sexual difficulties
    Social isolation and phobia
    Can't fit in seats in Cinemas Aircraft etc


Systematic Review

Respiratory:-
    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.

Cardiovascular:-
    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 Health If 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.


Mental History

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


Endocrinology


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


Eating Habits

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?


Sleep Habits

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?


Exercise

Do you have an exercise program?
Do you have a personal trainer?
I exercise hours a week.
I exercise:
    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.


Weight Loss

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:
    Lap band.
    Sleeve.
    Bypass.
    Vertical sleeve gastrectomy.
    Gastric Balloon.
   Other: .

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.
   Other:

What surgery would you like to have?

 

Please take the time to scroll through the answers you have given before submitting your patient questionnaire form.

When you activate the "Submit" button below, you will successfully your survey to Sydney Metabolic Surgery

Please send me an email copy of my patient questionnaire response.

 

Sydney Metabolic Surgery, ABN 64512622361, 17/20-24 Castlereagh St, Penrith NSW 2750 Phone:+61 (0)2 4721 8690 Click to contact
website designed and maintained by supportingsite.biz Site Disclaimer

go to top of page