Microsoft word - patient profile 2.doc

PERSONAL DETAILS

Surname: _________________________________ Given Names:___________________________
Address:_________________________________________________________________________
_________________________________________________Postcode:_______________________
Telephone No: (Home) ________________________ (Bus): _______________________________
Mobile No:____________________________ Date Of Birth ________________ Age ___________ Email:___________________________________________________________________________ Health Insurance Fund:_____________________________ Membership No: __________________ Medicare Number: _____________________ No. on Card:__________________ Exp: __________
Veteran Affairs: _______________________________________ Exp: ________________________
Pension Card: ________________________________________ Exp: ________________________

NEXT OF KIN (mandatory)

Name:__________________________________________ Relationship:______________________
Telephone No:________________________________
REFERRAL DETAILS
It is very important that your GP and Specialist doctors are informed of your weight loss especially if
you are taking medication for any related problems. Please infom the clinic of all yoir doctors.
GP Details: :_____________________________________________________________________
Address:____________________________________________Phone:________________________
Specialist Doctors: ________________________________________________________________
________________________________________________________________________________
HOW DID YOU HEAR ABOUT EASTERN OBESITY CLINIC?
Newspaper Magazine/Courier Website General Practitioner Family/Friend __________________________ Other _____________________________ Office Use only
WEIGHT HISTORY
What is your current weight? ___________ maximum weight? ________

Cause Of Xs Weight/Food weakness (circle):
Alcohol/Liquids Pregnancy-Related Other Causes____________________________________________________________________

What’s Been Tried?
Other__________________________
How seriously have you tried these measures? (circle);
Most amount of weight loss ___________ How long maintained __________ (months)
Why do you feel it didn’t work?: _______________________________________________
Exercise At Present Time:
__________________________________________________________________________

How long have you been thinking about weight loss surgery / balloon?
________________ _______________________________________________________
What research have you done? (circle); info night, know someone who has had the procedure,
internet, brochure, consult with obesity surgery staff, other __________________________
Do you feel you have a reasonable knowledge of the following procedures (circle);
Gastric balloon, Laparoscopic Gastric Band, or Laparoscopic Sleeve (tube) Gastrectomy Do you have support from (please circle); family, partner, local doctor, specilialist, friend, other
(list) _________________________________________________________________ What is your motivation (circle); energy level, short or long term health, appearance,
self esteem, fear of premature death, comorbid disease control, comorbid disease prevention, social isolation, mobility, other (list) _________________________________________________________ PERSONAL MEDICAL HISTORY

Are you planning to get pregnant soon? Details:

Have you ever suffered with any of the following health problems:
Arthritis/ joint pain / joint surgery Yes Please list all allergies,including drugs, dressing or food.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please give details of any major illnesses/problems:
_____________________________________


Please list all past operations
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Do you take any regular medications?(please list strength and frequency)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Please list all vitamins and supplements you take
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
ALCOHOL:
Do you drink alcohol? Never Rarely Regularly
How many standard glasses do you drink per day/week? ______________
SMOKING:
Do you smoke? Yes No Never If yes: how many per day? ___________________
Have you smoked in the past? Yes No If so, how many per day?
____________________
FAMILY MEDICAL HISTORY
Do you have a family history of any of the following and if so, please indicate: OTHER RELATIVES
(cousins, aunts,
grandparents etc)

Source: http://www.gastricballoonaustralia.com.au/pdf/gastric_balloon_australia.pdf