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Brisbane Weight Loss Surgery
Brisbane Weight Loss Surgery
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07 3720 9057
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Brisbane Weight Loss Surgery
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Dr Ian Martin
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Medical History Form
Bariatric Questionnaire
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Brisbane Weight Loss Surgery - helping you achieve a healthier lifestyle.
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Patient Resources
Medical History Form
Medical History Form
Contact Form:
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Date of Birth
*
DD
MM
YYYY
Email
*
Phone
*
Weight/Medical History
Height
*
Current Weight
*
Previous Maximum Weight
*
Please list all allergies, including drugs or dressings
*
Previous Surgeries
Do you take any regular ‘blood thinning’ medications?
*
Aspirin
Cartia
Warfarin
Plavix
Iscover
Eliquis
Pradaxa
Xarelto
Other
None
Other Medications
Do you take any other regular medications? (please list)
Alcohol
How many standard glasses of alcohol do you drink?
Average Per day:
*
Average Per week:
*
Smoking
Do you smoke?
*
Yes
No
How many per day?
Previous smoker?
*
Yes
No
How many per day?
Year ceased?
Do you or have you suffered with any of the following health problems:
Diabetes
*
Yes
No
Details
Gestational Diabetes (Diabetes while pregnant)
*
Yes
No
Details
Asthma
*
Yes
No
Details
Respiratory/Breathing/Sleep Apnoea
*
Yes
No
Details
Arthritis
*
Yes
No
Details
High Blood Pressure
*
Yes
No
Details
Heart Disease
*
Yes
No
Details
High Cholesterol
*
Yes
No
Details
Heartburn or Gastroesophageal Reflux
*
Yes
No
Details
Depression/Anxiety
*
Yes
No
Details
Email
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Brisbane Weight Loss Surgery
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