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Brisbane Weight Loss Surgery - helping you achieve a healthier lifestyle.
Home
Patient Resources
Medical History Form
Medical History Form
Contact Form:
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Occupation
*
Age
*
Date of Birth
*
DD
MM
YYYY
Email
*
Phone
*
COVID
Have you had COVID vaccinations?
*
No
Yes, First Vaccination
Yes, Second Vaccination
Yes, Booster (Third) Vaccination
Have you had COVID?
*
Yes
No
Date
DD
MM
YYYY
Weight/Medical History
Height
*
Current Weight
*
Is this your heaviest weight?
*
Yes
No
What is your heaviest weight?
Do you have any known drug or dressing allergies?
*
Yes
No
Please list all allergies, including drugs or dressings
Previous Surgeries (please write none if no surgeries)
*
Have you ever had a blood clot?
*
Yes
No
Details
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 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
This field is for validation purposes and should be left unchanged.
Brisbane Weight Loss Surgery
Scheduling an appointment is an important first step towards sustainable weight loss and a healthier, brighter future.
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